Every finding on record at Minneapolis Healthcare and Rehabilitation Center

The facility had a census of 44 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for foodborne illness. Findings included: - On 05/12/25 at 07:35 AM, observation revealed dietary staff in the facility kitchen preparing and serving breakfast to the residents. Dietary Staff (DS) CC wore a beard net but did not cover his sideburns or mustache and had a hair net that did not cover the back of his hair. On 05/13/25 at 11:20 AM, observation in the facility kitchen revealed DS CC prepared food without covering his sideburns or mustache, and his hairnet stopped at the back of his head. Approximately one inch of hair at the back of his head was uncovered. Further observation revealed DS CC had long, full sideburns in front of his ears to his jawline, and his mustache which were not covered with a beard net while he prepared drinks and desserts for the residents. DS CC hairnet he wore on his head did not contain the hair at the lower backside of his head. On 05/14/25 at 10:00 AM, DS BB stated staff were to wear hairnets, cover beards, and have thorough hair coverage including mustaches and sideburns with a beard net. The facility's Food Safety and Sanitization policy, dated 2017, documented all local, state, and federal standards and regulations would be followed to ensure a safe and sanitary department of food and nutrition services. The policy documented all staff would be in good health, would have clean personal habits, and would use safe food handling practices. Employees were required to have their hair styled so that it did not touch the collar, and wear clean aprons, clothes, shoes, and hair restraints were required and should cover all hair on the head. [NAME] nets were required when facial hair was visible.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 44 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 05/14/25 at 07:35 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 05/14/25 at 09:00 AM, Dietary Staff BB verified she was not a certified dietary manager and stated she had completed the course and needed to take the test to become certified. Dietary Staff BB stated the facility had two residents with a pureed diet. On 05/16/24 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The facility's Director of Food and Nutrition Services dated 2017, documented that the director of food and nutrition services would be responsible for the safe, sanitary, economical, and nutritional operation of the food and nutrition service department. The policy documented the director would be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. The director of food and nutrition services or designee would be considered the immediate supervisor of the cooks/chefs and other food and nutrition services staff. Support staff work under the supervision of the registered dietician nutritionist.

The facility identified a census of 44 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1's safety needs were met during transportation from dialysis (a procedure where impurities or wastes were removed from the blood). On 10/21/24, R1 was picked up from dialysis by transportation driver Certified Nurse's Aide (CNA) M, twenty-one miles from the facility. CNA M failed to strap R1's wheelchair into the van with the front safety harnesses. CNA M stopped at the stop light and when he drove away from the stop light, R1's wheelchair fell backwards in the transportation van and R1 hit his head on the wheelchair ramp. CNA M pulled over and was able to get R1 back in his wheelchair and transported R1 to the emergency room . At the emergency room , R1 was diagnosed with multiple cervical spine (C-the uppermost part of the spine, consisting of seven bones) fractures. The facility's failure to safely anchor the front of R1's wheelchair during van transport placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), end stage renal disease (ESRD-a terminal disease of the kidneys), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dependence on a wheelchair. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 14, which indicated intact cognition. The MDS documented R1 had impairment on both sides of his upper extremities and impairment on one side of his lower extremities and used a wheelchair for mobility. The MDS documented R1 had not had any falls during the assessment period. The Functional Abilities Care Area Assessment (CAA), dated 01/29/24, documented R1 required staff assistance with all of his activities of daily living (ADLs), was able to make his needs and wants known, and was participating in therapy to regain strength. The Falls CAA, dated 01/29/24, documented R1 had one fall during the assessment period. The CAA documented R1 required assistance with his ADLs but was non-compliant with asking for assistance. R1's Care Plan documented R1 as dependent on staff for bathing and putting on and taking off his footwear. The care plan documented R1 required substantial/maximum assistance from staff for toileting, dressing, personal hygiene, sit-to-stand, and transfer. The care plan documented R1 as independent with mobility in his wheelchair. The care plan documented R1 as at risk for falls due to vision impairment, impulsivity, poor choices, and weakness. R1's Morse Fall Scale, dated 10/10/24, documented R1 had a fall score of 80, which indicated R1 had a high risk for falls. The Facility Incident Report, documented on 10/21/24at approximately 11:30 AM Social Services Designee (SSD) X received notification from CMA M stating he picked R1 up from dialysis. CNA M stated R1 was sitting in his wheelchair in the rear of the van and CNA M was driving down the street and stopped at a stoplight. When the light turned green, CNA M started to go and R1's wheelchair tipped backwards causing R1 to strike his head on the ramp at the back of the van. CNA M pulled over and assisted R1 back into a sitting position in his wheelchair and took R1 immediately to the emergency room for evaluation. CNA M was suspended pending investigation. CNA M stated he did not hook up the wheelchair in the front. R1 was released from the emergency room and returned to the facility at approximately 09:20 PM on 10/21/24. R1 had a C6 (cervical fracture at the level of the sixth bone) fracture, and a cervical collar (C-collar: provides support and restricts movement of the neck while neck bones and tissues heal) was in place. The investigation showed R1's wheelchair was not properly secured per staff and resident interviews. The facility re-educated all staff on Abuse, Neglect, and Exploitation (ANE), performed Driver Basic Skills Validation with approved drivers, and implemented a Pre-Transportation Safety Checklist which would be monitored weekly for four weeks, every two weeks for four weeks, and then monthly for four months. CNA M's Witness Statement, dated 10/21/24, documented CNA M stopped at a red light and when it turned green, he accelerated and R1, who was in the wheelchair fell backwards. CNA M stated he went to get R1 out of the van and when he let down the wheelchair ramp R1 slipped out of his wheelchair. CNA M laid R1 down on the wheelchair ramp and got R1's wheelchair out of the van. A man stopped and helped CNA M pick R1 up and set R1 back in the wheelchair. CNA M then strapped R1 down and took R1 to the emergency room . CNA M stated the incident occurred because he did not hook up R1's wheelchair in the front with the safety harnesses. The Nurse's Note, dated 10/21/24 at 12:15 PM, documented R1's next of kin was notified of his fall and R1 being transported to the emergency room . The Nurse's Note, dated 10/21/24 at 12:16 PM, documented R1's primary care physician was notified of his fall. The Emergency Department Report, dated 10/21/24, documented R1 presented to the emergency department for evaluation after falling out of his wheelchair. R1 arrived with a staff from the nursing facility. R1 completed dialysis and the resident's the wheelchair was not secured in the transport vehicle. When the transport vehicle started moving, R1's wheelchair fell backward hitting the back of his head against the floor of the transport vehicle. R1 complained of a headache and posterior neck pain. The Cervical Spine Computed Tomography [CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels] Scan Results, dated 10/21/24, documented R1 had sustained an acute bilateral (both sides) C6 lamina fracture, and acute bilateral C6 inferior articulating facet fractures (cervical neck fracture with dislocation), and an acute distracted fracture (a break in a bone where the bone components widen, resulting in an increase in the bone's overall length) of the spinous process of C5. The Assessment and Plan, dated 10/21/24, documented due to R1 having numerous medical comorbidities, it would be ideal to avoid surgery and consider non-surgical interventions as R1 was a high-risk patient. The neurosurgeon advised a cervical collar and to watch healing closely with repeat X-rays. The neurosurgeon discussed with R1 the necessity to wear the cervical collar at all times but said R1 could take it off daily to clean underneath the collar while maintaining cervical spine precautions. The neurosurgeon stressed to R1 to watch for numbness or tingling, worsening pains, trouble using his arms and legs from his baseline, or any changes in bowel or bladder habits. R1 stated he would like to proceed with this course of action. The plan noted to get X-rays in a couple of weeks, allow R1 to discharge, and maintain cervical spine precautions at all times. The Nurse's Note, dated 10/21/24 at 06:43 PM, documented R1's next of kin was updated on R1's condition. The Nurse's Note, dated 10/21/24 at 09:50 PM, documented R1 returned from the emergency room via facility van. R1 returned with a neck brace with instructions not to remove it but once a day for cleaning. The Nurse's Note, dated 10/21/24, documented the facility notified R1's primary care provider at 07:00 PM the C6 fracture from the fall. The Change of Condition Follow Up, dated 10/22/24, documented R1's pain level was a four and R1 stated he was having moderate pain to his neck area. R1 complained of discomfort from the C-collar. Staff administered R1 pain medication. R1 was angry and wanted to remove the C-collar. The Nurse's Note, dated 10/22/24, documented R1 had moderate pain from a fall that had occurred the previous day. R1 needed to be repositioned in his chair every fifteen to thirty minutes the entire shift due to his bottom sliding forward and his body lying to one side in the chair. R1 refused to lie in bed and was given education on how lying in bed could be beneficial to healing and aligning his body. R1 stated, I don't think so. This is fine. R1 continually asked for the C-collar to be removed as it was uncomfortable. Staff educated R1 on why the C-collar could not be removed. R1 initially refused to eat his meals stating he could not eat with the C-collar on and asked for the C-collar to be removed so he could eat. Staff educated R1 that he would have to learn to eat with the C-collar on as it could not be removed. R1 then required one staff assistance for eating and ate all of his food. R1 required two to three staff for all transfers as he was very weak. The Nurse's Note, dated 10/22/24, documented staff brought R1 to the dining room to be assisted with the dinner meal. R1 called the aide a name and stated, I would rather starve to death than have to do this. The aide asked R1 if she could finish helping him eat and R1 said no. The Change of Condition Follow-Up, dated 10/23/24, documented R1 had no complaints, slept well, and awakened easily. R1 stated he was a little achy from the accident. The Change of Condition Follow Up, dated 10/23/24, documented R1 was alert and oriented, able to make his needs known and was a little weak. The Change of Condition Follow-Up, dated 10/24/24, documented R1 was sore and weak, verbalizing needs, and had no concerns. The Nurse's Note, dated 10/26/24, documented the nurse went to R1's room to administer medications that morning. R1 sat in his recliner and leaned to his right side, and the C-collar was not positioned correctly on R1. The collar was over R1's chin and covered his mouth and nose region. The nurse sat R1 up straight, supported the C-spine, and placed the C-collar on correctly. R1 asked why he could not wear the collar the way it was because it was comfortable. The nurse educated R1 on the need to wear the collar correctly. R1 stated he did not care, he wanted it off. The Nurse's Note, dated 10/26/24, documented R1 was assisted up to his wheelchair and brought out to the dining room for breakfast so the aide could assist him with his meal. R1 did not argue and was pleasant to the staff. R1 ate 75% of his breakfast and then was assisted back to his recliner in his room. R1 asked to be shaved because his facial hair was bothering him with the collar. The Nurse's Note, dated 10/26/24, documented the nurse was asked by the aide to readjust R1's C-collar as the collar was over his chin and covered his mouth area again. The nurse asked R1 if he was moving the C-collar. R1 denied touching the collar. The nurse educated R1 again on the reason why the C-collar needed to be in the correct position. After properly placing the C-collar, R1 was repositioned in his recliner and propped up with more pillows. The Nurse's Note, dated 10/26/24, documented the nurse went to R1's room to deliver noon medications and saw R1 pulling at the C-collar and moving his head back and forth then grabbing at the Velcro. The nurse asked R1 what he was doing and R1 said sleeping. The nurse again educated R1 that the C-collar must be left in the proper position, or he would not heal properly. R1 stated I don't care. I don't like it on. The Nurse's Note, dated 10/26/24, documented the nurse went to R1's room two more times to re-adjust the C-collar. R1 continued to pull his chin out of the C-collar so that his neck was tucked down. R1 stated he was not touching the C-collar, but staff have seen R1 pulling at the Velcro and chin area and wriggling his head down. The Nurse's Note, dated 10/26/24, documented R1's C-collar was again above his chin covering his mouth and nose. The nurse repositioned the C-collar again and assisted R1 to the wheelchair to come out for the dinner meal. The Nurse's Note, dated 10/27/24, documented the nurse went to R1's room and he had the c-collar on correctly. R1 took his medications without difficulty, transferred to the wheelchair with two staff assist, and complained of pain at a 3 out of 10. R1 came out for breakfast, and he ate 75% of his meal. On 12/28/24 at 12:15 PM, observation revealed R1 sat at the lunch table in his wheelchair being fed by a CNA. R1 had the C-collar in place correctly. On 12/28/24 at 09:30 AM, Administrative Staff A stated the transportation driver admitted he did not hook up the wheelchair safety straps to the front of R1's wheelchair. Administrative Staff A stated the facility suspended the transportation driver immediately and ended up firing him because of his lack of concern for R1's safety in the transportation van. Administrative Staff A stated re-education had been completed with all the other staff that were trained on transportation. ANE re-education had been completed with all staff on 10/21/24 after the accident had been reported back to the facility. Administrative Staff stated she expected all staff who drove the facility van to have all residents safely and correctly buckled in with all safety straps and harnesses. On 12/28/24 at 12:30 PM, R1 stated he was very upset that this happened to him because it could have been avoided if the driver had just paid attention to what he was doing. R1 stated he was in a lot of pain from his injury. R1 said he was angry that he had to be fed like a baby. The facility's Staff Vehicle Safety Policy and Procedure dated 2021, documented the purpose of the policy was to prevent vehicle accidents and to promote the safety of residents and employees while using facility vehicles. The Resident Securement Checklist, documented Pre-securement: Ensure that the resident is seated properly in the wheelchair. The resident's back should completely touch the seatback without spaces; Evaluate cushion usage for safety; Check that you have all the following equipment: four securement straps per wheelchair, one seat belt per wheelchair, and one shoulder strap per wheelchair; Make sure all the equipment is in good working order; and Check that the securement tracks are clean. Wheelchair Securement: Put the wheelchair into position and lock the brakes; Secure the front straps: anchor straps on the floor track three inches outside the front wheels, ensure straps are at a 30-45 degree angle, secure close to the seat surface, and ensure the track fittings and straps are secure by tugging at them; Secure the rear straps: anchor straps on the floor track three inches outside the rear wheels, ensure straps are at a 30-45 degree angle, secure close to the seat surface, and ensure the track fittings and straps are secure by tugging at them. Lock the brakes. Put on the resident's seat belt with the lap belt buckle on the hip opposite of the shoulder strap to be used. Ensure the belt fits tight across the lap and under the wheelchair armrest. The facility's failure to safely anchor the front of R1's wheelchair during van transport resulted in a cervical spine fracture for R1 and placed R1 in immediate jeopardy. On 10/28/24 at 12:51 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed the facility's failure to ensure a safe environment free from preventable accidents evidenced by staff failure to buckle the front wheelchair harness during motor vehicle transport placed R1 in IJ. On 10/21/24, the facility completed ANE education with all facility staff, performed Driver Basic Skills Validation with approved drivers on 10/21/24, implemented a Pre-Transportation Safety Checklist which would be monitored weekly for four weeks, every two weeks for four weeks, and then monthly for four months. CMA M was terminated. Since all corrective actions were completed prior to the onsite survey, the deficient practice was deemed past noncompliance and remained at the scope and severity of J.

The facility had a census of 42 residents. The sample included 12 residents with one reviewed for dialysis. Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of the resident's dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment, including monitoring for Resident (R)26. This placed the resident at risk for complications and health decline. Findings included: - R26's Electronic Health Record (EHR) documented R26 had diagnoses of end stage renal disease (decline in kidney function.) R26s Quarterly Minimum Data Set (MDS), dated [DATE], recorded R26 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded he required limited assistance of one staff for bed mobility, transfers and toilet use. The MDS further recorded R26 was occasionally incontinent of urine and recorded the resident received dialysis treatment. The Dialysis Care Plan, dated 07/26/23, documented R26 received dialysis three times a week on Mondays, Wednesday and Friday. The Physician Order, dated 08/28/23 directed staff R26 required dialysis three times a week. The facility lacked evidence of communication and collaboration from the dialysis center to the facility for orders, guidance or direction with each appointment the resident had at the dialysis center. On 09/07/23 at 10:15 AM, observation revealed R26 sat in a recliner in his room while Licensed Nurse G administered the resident's morning medications. Continued observation revealed the resident was dressed in street clothes and nicely groomed. On 09/12/23 at 11:00AM, Administrative Nurse D verified R26 received dialysis three times a week on Mondays, Wednesdays and Fridays, and the facility should send a communication sheet with the resident with each dialysis treatment when he left the facility. Administrative Nurse D did say if the sheet was sent, the dialysis center failed to send the communication form back with the resident with each appointment. The facility's Hemodialysis policy, undated, documented the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of the residents receiving hemodialysis. The facility would assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. The ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The license nurse may communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form when appropriate, that would include, but not limited to timely medication orders, physician/treatment orders, laboratory values, and vital signs. changes or decline in condition related to the vascular access site, dialysis adverse reaction/complications and or recommendations for follow up observation and monitoring, dialysis treatment provided, , nutritional fluid management, occurrence of risk or falls and any concerns related to transportation to and from the dialysis facility. The facility failed to provide R26 dialysis communication form, and/or failed to receive the dialysis communication from when sent with R26, appointments to the dialysis facility, with each appointment placing the resident at risk for complications and health decline.

The facility had a census of 42 residents. The sample included 12 residents, with five reviewed for falls. Based on observation, record review, and interview the facility failed to implement meaningful, resident centered interventions for two sampled residents, Resident (R) 21 and R29, who were at risk and had falls. This placed the residents at increased risk for falls and injury. Findings included: - The Electronic Medical Record (EMR) documented R21 had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), abnormalities of gait and mobility, unsteadiness on feet, need for assistance with personal care, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), pain, and vertigo (a sensation of whirling and loss of balance). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R21 had severely impaired cognition and required extensive assistance of one staff for personal hygiene and limited assistance of one staff for bed mobility, transfers, ambulation, dressing, and toileting. The MDS further documented R21 had steady balance, no functional impairment, and had no falls. The Quarterly MDS, dated [DATE], documented R21 had severely impaired cognition, and required extensive assistance of one staff for bed mobility, transfers, ambulation in his room, dressing, toileting, and personal hygiene. The MDS further documented R21 had unsteady balance, no functional impairment, and had on fall since prior assessment. The Fall Risk Assessments, dated 10/28/22, 01/26/23, 02/17/23, 03/02/23, 03/08/23, 05/19/23, 07/10/23, documented R21 a high risk for falls. The Fall Care Plan, dated 08/14/23, documented R21 was at risk for falls. The care plan initiated on 12/31/20 directed staff to make sure his call light was within reach and encourage him to use it for assistance as needed, respond promptly for all requests for assistance, and anticipate and meet his needs. The update dated, 01/06/23, educated staff the importance of meeting the resident's basic needs in a timely manner. The update, dated 03/02/23, directed staff to place a sign on R21's walker to use his call light for assistance. The update, dated 03/08/23, directed staff to place a sign in the bathroom to remind R21 to use his call light for assistance. The update, dated 07/10/23, educated staff to put R21's walker by his bed when he was in bed and place a sign on his walker to press his call light for assistance. The Fall Investigation, dated 01/06/23 at 06:55 PM, documented staff heard hollering for help from R21's room and observed R21 lying on the floor next to his bed. R21 was assisted off the floor by two staff members with a gait belt without difficulty and was taken to the bathroom. The investigation documented R21 did not have any injuries, was incontinent, had impaired memory, and had attempted to self-transfer from his wheelchair to his bed. The investigation further documented staff was educated to not leave a cognitively impaired resident alone or ask to wait for assistance. The Fall Investigation, dated 03/02/23 at 12:15 AM, documented staff heard hollering for help from R21's room and observed him on the floor on the right side on the bed with head just under the bed with his legs sticking out. The investigation documented R21 had a raised, fluid filled 2 centimeters (cm) area on the right outer aspect occiput on the back of his head, had impaired memory, gait imbalance, and the physician directed staff to notify him if R21 had any changes. The investigation further documented staff were directed to put a note on his walker to call for assistance to the bathroom. The Fall Investigation, dated 03/09/23 at 06:41 PM, documented staff heard a thump sound and observed R21 with his right side against the bathroom door and he stated he attempted to stand up from the toilet, fell to the right, hit his head on the door, when he pulled his pants up. The investigation further documented R21 had impaired memory, impaired gait and balance, weakness and staff were directed to place a sign in the bathroom to remind R21 to use his call light. The Fall Investigation, dated 07/10/23 at 06:31 PM, documented staff hear hollering for help and observed R21 lying on the floor and he stated he needed to use the bathroom. The investigation further documented R21 obtained a skin tear to his left elbow. The investigation further documented R21 had been taken to the bathroom [ROOM NUMBER] minutes prior to the fall. The investigation documented R21 only had socks on when attempted to take himself to the bathroom, and directed staff to place his walker within reach with a note to call for assistance. On 09/07/23 at 02:09 PM, observation revealed Certified Nurse Aide (CNA) N sat R21 on the side of the bed, placed a gait belt around his waist, put the walker in front of him and tried to assist him to stand up. Further observation revealed R21 could not stand up straight, and sat back down on the bed. CNA N assisted him again to try to stand up, at that time he was able to stand up and used his walker to walk to the bathroom, and sat on the toilet. On 09/07/23 at 02:09 PM, CNA N stated she was unsure if she was able to look at the resident's care plan to know what all the interventions were to prevent him from falls but would contact the nurse if he had a fall. On 09/11/23 at 08:00 AM, Licensed Nurse (LN) H stated R21 had not had any falls on the day she works at the facility, and that he was on hospice (a program designed to make the process of dying as comfortable as possible), was a one person assist with transfers and ambulation. On 09/12/23 at 11:28 AM, Administrative Nurse D stated she was unable to inform me of her expectations of staff for prevention of falls until she reviewed his care plan. The facility's Fall Prevention policy, dated 02/01/20, documented the care plan would be assessed for the risks of falling and the resident would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy further documented, if a resident with high risk protocol, staff implement interventions from low/moderate risk protocols and interventions would be implemented that address unique risk factors by the risk assessment tool. Each resident's risk factors, environmental hazards would be evaluated when developing the resident's comprehensive care plan and monitored for effectiveness. The facility failed to implement meaningful, person centered interventions which addressed the causative factors for falls for cognitively impaired R21. This placed the resident at risk for further falls and injuries. - The Electronic Medical Record (EMR) for R29 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), abnormalities of gait and mobility, history of falling, and muscle weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The assessment further documented R29 had unsteady balance, no functional impairment, and had no falls. The Quarterly MDS, dated [DATE], documented R29 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation in room, dressing, toileting, and limited assistance of two staff for personal hygiene. The MDS further documented R29 had unsteady balance, no functional impairment, and no falls. The Fall Assessments, dated 01/23/23, 02/19/23, 02/28/23, 04/29/23, 07/15/23, 08/18/23, 08/23/23, and 09/06/23, documented R29 a high risk for falls. The Fall Care Plan, dated 07/31/23, documented R29 was at risk for falls. The care plan initiated on 4/07/22 directed staff to reeducate R29 to use the call light for assistance when transferring. The update, dated 06/7/22, directed staff to reeducate R29 to use the call light for assistance with transfers. The update dated 02/28/23 directed staff to reeducate R29 to call for assistance to the bathroom at night. The update, dated 08/17/23, directed staff to use 2 staff assist with transfers until R29 felt better. The update, dated 08/23/23, documented anti-rollback brakes placed on the wheelchair. The update, dated 08/28/23, directed staff to be sure R29's call light was within reach and encourage her to use it for assistance as needed and to respond quickly to all requests for assistance. The update, dated 09/06/23, reeducated staff to make sue resident has shoes on for transfers and a note was placed in R29's room to use the call light for assistance. The update, dated 09/08/23, directed staff to use 2 staff for transfers at all times. The Fall Investigation, dated 02/28/23 at 04:25 AM, documented staff heard R29 say, OH, and observed R29 fall onto her bottom in the bathroom; her right arm hit the wall and she sustained a skin tear to her right upper forearm. The Investigation further documented R29 had gait imbalance, fell after she lost her balance getting onto the toilet and had not utilized her call light for assistance. The investigation documented R29 was educated to use the call light and wait for assistance to go to the bathroom. The Fall Investigation, dated 09/06/23 at 07:30 AM, documented R29 slid to the ground during a transfer to her wheelchair with staff. The investigation further documented R29 had impaired memory, gait imbalance, and weakness, and sustained a skin tear to her right elbow. The investigation documented staff were reeducated to ensure R29 had shoes on during transfers. The Fall Investigation, dated 09/06/23 at 06:30 PM, documented R29 fell to the floor while she attempted to transfer herself. The investigation documented staff had just told R29 to wait a minute as they were assisting another resident and R29 decided to transfer herself. The investigation documented R29 had impaired memory, gait imbalance, and staff were educated to place a sign in the resident's room to press her call light for assistance. The Fall Investigation, dated 09/08/23 at 01:35 PM, documented R29 was on the floor in her bathroom with her back against the adjoining room door, legs stretched out in front of her, and a gait belt around her waist. The investigation further documented staff were assisting R29 when she lost her balance, fell over, and reopened a healing skin tear on her right arm. The investigation documented R29 would be a two-person transfer. On 09/07/23 at 03:00 PM, Certified Nurse Aide (CNA) M stated she needed to find a second CNA to assist her to transfer the resident as she had two falls the previous day and she was now a two-person transfer. Observation revealed CNA M placed a gait belt around R29's waist, took her wheelchair pedals off, CNA M on her left side and CNA N on her right, stood R29 in front of her walker, held on to her gait belt as R29 was unsteady, and walked her into the bathroom, and assisted her to the toilet. Further observation revealed CNA N stated she was going to go assist another resident and CNA M should be ok now. CNA M asked if she was coming back to assist her and CNA N stated she did not think she needed to. CNA M told her that she had been told that R29 was a two person transfer because of her two falls and CNA N stated she had not attended report, so she did not know that R29 was now a two person assist. On 09/12/23 at 11:28 AM, Administrative Nurse D stated R29 would be admitted to hospice (a program designed to make the process of dying as comfortable as possible) due to her decline and multiple falls and she was unable to inform me of her expectations of staff for prevention of falls until she reviewed her care plan. The facility's Fall Prevention policy, dated 02/01/20, documented the care plan would be assessed for the risks of falling and the resident would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy further documented, if a resident with high-risk protocol, staff implement interventions from low/moderate risk protocols and interventions would be implemented that address unique risk factors by the risk assessment tool. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive care plan. The facility failed to implement meaningful, person-centered interventions which addressed the causative factors for falls for R29. This placed the resident at risk for further falls and injuries.

The facility identified a census of 41 residents with three reviewed for falls. Based on record review, observation and interview, the facility failed to prevent an avoidable accident when Resident (R) 1 fell out of the transportation van after an appointment due to the brakes to R1's high backed wheelchair were not fully engaged on both sides, resulting in R1's wheelchair rolling and R1 slid out of her wheelchair, falling on the ground, and sustaining a non-displaced humerus (upper arm) fracture. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of myotonic muscular dystrophy (group of inherited disorders that involve muscle weakness and loss of muscle tissue, and worsen over time), respiratory failure, and protein calorie malnutrition. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS), score of 15, which indicated she was cognitively intact. The MDS documented R1 required extensive assistance of two staff for bed mobility, transfer, locomotion on and off the unit, toileting, dressing, and personal hygiene. The MDS documented R1 required assistance with a tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), a gastronomy tube (surgical creation of an artificial opening into the stomach thru the abdominal wall), and R1 utilized oxygen at all times. The Activity of Daily Living Care Area Assessment (CAA) dated 01/18/23, documented R1 required extensive assistance for all activities of daily living and R1 would be care planned to minimize risks. The Fall CAA, dated 01/18/23, documented R1 was at risk for falls, required assistance for all her activities of daily living, had a diagnosis of myotonic muscular dystrophy, and would be care planned to minimize risks. The Activities of Daily Living Care Plan, dated 01/13/23, documented R1 had a self-care deficit and required assistance with her care needs due to a diagnosis of myotonic muscular dystrophy. The care plan directed staff R1 was dependent on two staff for bathing and required assistance of one to two staff for bed mobility, transfer, dressing, eating, and personal hygiene. The Fall Care Plan, dated 01/18/23, documented R1 was at risk for falls due to impaired mobility. The care plan directed staff to anticipate and meet R1's needs and to educate R1, her family and her caregivers about safety reminders. The Morse Fall Scale, dated 01/19/23, documented R1 had a score of 80, which indicated R1 was a high risk for falling. The Facility Incident Report, dated 01/19/23, documented R1 was out of the facility at a doctor's appointment when Transportation Driver GG assisted R1 up the ramp into the van in R1's wheelchair and pushed the brakes of the wheelchair to lock. Transportation Driver GG stepped down from the van to walk around to the other side to finish securing the chair, when the chair rolled forward some and R1, along with her cushion, slid forward off the wheelchair after the chair stopped. R1's left arm got tangled in the wheelchair arm when she slipped forward. The nurses and the doctor's office came out and assisted R1. R1 had no notable injury at that time and R1 declined to go to the hospital to be evaluated. When R1 returned to the facility, R1 complained of pain in her left arm and right ankle. R1's primary care physician was called and updated, and a new order was received for an x-ray at bedside. At approximately 07:30 PM, a radiology report was received with the impression of the left arm stating an irregularity involving the neck of the humerus, which could represent fracture of unknown age. R1's primary care physician was notified of the results and no new orders were received. On 01/20/23 the facility charge nurse followed up with R1's primary care physician and new orders were received for a Computerized Tomography (CT) scan of the left arm at 02:00 PM on 01/20/23. The CT scan results confirmed a fracture and R1 was sent to a higher level of care per R1's primary care physician. On 01/20/23 at 11:35 PM, R1 returned to the facility after the CT scan was reviewed by the orthopedic team at the higher level of care. R1 had a sling to her left arm and orders for outpatient follow-up with orthopedics and an order for morphine (pain medication) 15 milligrams (mg) as needed. The Witness Statement, dated 01/23/23, documented Transportation Driver GG stated when she loaded R1 into the van on 01/19/23 at approximately 2:20 PM, the left sliding door of the van had bumped R1's foot. Because of this, upon loading R1 into the van for the return to the facility, Transportation Driver GG opened both left and right-side sliding doors of the van to check for clearance on both sides. Transportation Driver GG stated she loaded R1 into the van and she thought she had applied the brake on the right side of the wheelchair, and she reached to apply the left brake and due to limited clearance on the left side she asked R1 to check that the left brake was set. Transportation Driver GG stated she then exited the van and her weight on the ramp caused the wheelchair on the van to move. Transportation Driver GG heard R1 say, Oh. Transportation Driver GG stated she turned and saw the chair move forward through the left side doorway causing R1 to slide out of the chair along with the cushion. Transportation Driver GG stated she immediately went around the van and checked on R1, asking if she was okay and covering her with a blanket, and then told the greeter that she needed medical assistance because R1 was on the ground. Transportation Driver GG then went back to R1 to see if she could make R1 more comfortable. R1 wanted Transportation Driver GG to move her legs. Transportation Driver GG moved R1's legs cautiously and R1 showed not discomfort. R1 then asked Transportation Driver GG to move her left arm which was between the van door and the wheelchair arm rest. Transportation Driver GG moved R1's left arm cautiously and she could tell it was painful to R1. A nurse finally came and called for another nurse, and they all lifted R1 back into her chair. Transportation Driver GG asked R1 if she was okay and R1 replied, Yes. The Transportation Driver GG asked the nurses if they felt R1 should be seen by a doctor and the nurses asked R1 what she wanted to do and R1 replied she wanted to go home [to the facility]. R1 was then secured in the van and taken back to the facility. On 01/30/23 at 10:15 AM, Transportation Driver GG stated that she had transported R1 to a doctor's appointment on 01/19/23 using the side loading van. When Transportation Driver GG had put R1 into the side loading van when leaving the facility, R1 had told her that she had bumped her foot on the left door. Transportation Driver GG stated to protect R1's foot, she opened both doors to make sure there was enough clearance. Transportation Driver GG she thought she had locked the right brake, but because of the occurrence, she was no longer certain. She said she asked R1 to lock the left side brake because there was not enough clearance between the back seat and the wheelchair for Transportation GG to get her arm back there to lock it. Transportation GG then got off the van and thinks that perhaps her weight must have shifted the van because the wheelchair moved and R1 slid off the wheelchair with her wheelchair cushion and landed on the ground. On 01/30/23 at 11:00 AM, Administrative Nurse D stated she expected transportation staff to ensure both brakes were fully engaged and functioning. The facility's Staff Vehicle Safety Policy and Procedure policy, revised May 2022, documented Only the trained driver may secure residents in the vehicle. The driver may not delegate this responsibility to any other person unless that person is also trained in securing resident's in vehicles. The facility's undated Accidents and Supervision policy documented all staff are to be involved in observing and identifying potential hazards in the environment while taking into consideration of the unique characteristics and abilities of each resident. The facility should make a reasonable effort to identify the hazard and risk factors in the resident environment. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The facility failed to prevent an avoidable accident when R1 slid out of her wheelchair during a transportation event. As a result, R1 sustained a humerus fracture which caused discomfort and required R1 to wear a sling. On 01/19/23, prior to the survey, the facility completed corrective actions which included review of the incident, education, and training to relevant staff on how to safely load and transport the resident in the van. The deficient practice was cited as past noncompliance.

The facility had a census of 34 residents. The sample included five residents with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development or worsening of a facility acquired pressure ulcer for one of one sampled resident, Resident (R) 5. Findings included: - R5's Admission Minimum Data Set (MDS), dated [DATE], documented the facility admitted the resident on 09/14/20. The MDS documented the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of eight. The MDS documented the resident required extensive staff assistance with all activities of daily living (ADLs), at risk for pressure ulcers, and had no pressure ulcers. The MDS documented the resident had a pressure reducing device for chair and not on a turning/repositioning program. The Pressure Ulcer Care Area Assessment (CAA), dated 09/21/20, documented the facility admitted the resident with no pressure ulcer injuries and required staff assistance to complete ADL's. The ADL Care Plan, dated 09/18/20, documented R5 required one-two staff assistance to turn and reposition in bed. The Skin Care Plan, dated 09/18/20, documented the resident had potential/actual impairment to skin integrity related to fragile skin. The care plan directed staff to keep fingernails short, encourage good nutrition and hydration to promote healthier skin, follow facility protocols for treatment of [REDACTED]. The care plan documented the resident had skin tears on her right and left lower legs. The care plan lacked documentation the resident was at risk for pressure ulcers and interventions to prevent the development of pressure ulcers. The Admission Skin-Head to Toe Weekly Skin Check, dated 09/14/20, documented the resident had several skin tears all over her body and severe [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) with drainage on all four extremities. The Braden Scale Assessment, (assesses risk for pressure ulcer development) dated 09/14/20, documented a score of 17, indicating at risk for pressure ulcers. The Skilled Nurse's Note, dated 09/19/20, documented R5 had a skin tear on left arm and no other skin issues. The Braden Scale Assessment, dated 09/21/20, documented a score of 14, indicating moderate risk for pressure ulcers. The Skin-Head to Toe Weekly Skin Check, dated 09/21/20, documented the resident had a 2.5 centimeter (cm) x 3.5 cm blister on her left buttock. The Skilled Nurse's Note, dated 09/23/20, documented R5's had a scabbed skin tear and no other skin breakdown. The Braden Scale Assessment, dated 09/28/20, documented a score of 12, indicating high risk for pressure ulcers. The Skin-Head to Toe Weekly Skin Check, dated 09/28/20, documented the resident had an open blister on the top of her coccyx (small triangular bone at the base of the spine). The Braden Scale Assessment, dated 10/05/20, documented a score of 6, indicating very high risk for pressure ulcers. The physician's orders [REDACTED]. The order was discontinued on 11/01/20. The Skin-Head to Toe Weekly Skin Checks, dated 10/26/20, documented the resident's sacrum (large triangular bone between the two hip bones) had a 1 cm x 0.6 cm Stage 2 (partial thickness skin loss) pressure ulcer and a Stage 1 (non-blanchable red area) pressure ulcer on her coccyx. The physician's orders [REDACTED]. The order was discontinued on 11/03/20. On 11/03/20 at 11:30 AM, observation revealed R5 lying in bed on a scoop mattress (regular mattress with edges built in to define the edge), slightly tilted on her left side. At 12:10 PM, continued observation revealed Certified Nurse Aide (CNA) M raised the head of the bed to assist R5 to eat but did not reposition the resident off her left side. At 12:43 PM, continued observation revealed CNA M left R5's room without repositioning her. At 01:07 PM, continued observation revealed Administrative Nurse E asked R5 if she had pain, R5 rated pain in her back at a 6 (scale 0 - 10). Administrative Nurse E set the head of the bed up higher without repositioning R5 off her left side and administered pain medication. At 01:07 PM, continued observation revealed R5 requested to have staff come and straighten her out to make her more comfortable. At 01:10 PM, continued observation revealed Administrative Nurse D entered R5's room and R5 requested to be repositioned flat on her back due to back pain. Administrative Nurse D offered the resident a low air loss mattress and left the room, R5 was not repositioned. At 01:31 PM, continued observation revealed Administrative Nurse E and Licensed Nurse (LN) G entered R5's room for wound dressing change, R5 was not repositioned during wound dressing change to her lower legs. At 02:19 PM, continued observation revealed Administrative Nurse E and LN G rolled R5 onto full left side to change wound dressing to her buttocks and noted a red blanchable (press on a person's skin to push blood away and wait for return to determine blood circulation) area on R5's left outer hip. On 11/03/20 at 02:19 PM, observation revealed Administrative Nurse E and LN G removed an unmarked dressing from R5's left sacrum. The sacral wound had a red area that measured 9 cm x 7.7 cm with an opened area that measured 1 cm x 1 cm. Administrative Nurse E stated the opened area was considered a Stage II pressure ulcer and cleaned the area with wound cleanser, applied calcium alginate cut to fit the open area, covered with a clear adhesive dressing, and marked with initials and date. On 11/03/20 at 01:31 PM, LN G stated R5 did not have any pressure ulcers when she admitted to the facility. LN G confirmed the wound dressing was not dated and initialed by the nurse that applied it, and it was standard procedure to mark all dressings with initials and date applied. On 11/03/20 at 02:19 PM, Administrative Nurse E stated the opened area was considered a Stage 2 pressure ulcer and the nurses were to mark all dressings with initials and date applied. On 11/04/20 at 03:03 PM, Administrative Nurse D stated she expected the care plan to address the risk for pressure ulcers and include interventions to prevent pressure ulcers. Administrative Nurse D stated she expected the nurse who applied a dressing to label the dressing with the date applied and initialed, and staff should reposition the resident at least every two hours. The facility's Wound Treatment Management policy, dated 01/01/2020, documented staff would provide wound care to promote wound healing and provided evidence-base treatments in accordance with current standards of practice and physician orders. The facility failed to implement timely interventions to prevent pressure ulcers for R5, identified at risk for pressure ulcers, and developed a facility acquired Stage 2 pressure ulcer, placing the resident at risk for delayed wound healing.

The facility had a census of 34 residents. The sample included five residents. Based on record review and interview, the facility failed to follow physician's orders [REDACTED]. Findings included: - R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of nine. The MDS documented the resident required extensive staff assistance with all activities of daily living (ADLs), rejected care one to three days in the look back period, occasionally incontinent of urine, and had not received antibiotic medication in the look back period. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 02/28/20, documented the resident had occasional bladder incontinence and reported dribbling at times. R1 was aware of the urge to void and able to make her needs known. The CAA documented the resident required staff assistance with all ADLs, and directed staff to assist R1 with toileting and incontinence care as needed to ensure the resident was clean, dry, and odor free. The revised ADL Care Plan, dated 08/22/20, documented the resident required assistance of one staff with toileting. The revised Bladder Incontinence Care Plan, dated 08/22/20, directed staff to monitor and document signs and symptoms of UTI. (pain, burning, cloudiness, no output, deepening of urine color, increased temperature, increased pulse, fever, chills, altered mental status, change in behavior and/or change in eating patterns). The Progress Note, dated 10/09/20 at 12:30 PM, documented R1 lethargic (the state of dullness, prolonged sleepiness, sluggishness, or serious drowsiness), confused, and not acting herself. The note documented staff obtained the resident's temperature with a finding of 100.3 Fahrenheit (F-normal 98.2 F). Staff notified the physician who gave a verbal order to send resident to the emergency room . The Progress Note, dated 10/09/20 at 02:44 PM, documented the hospital emergency room reported R1 had a UTI, tested positive for COVID-19, was administered intravenous (medication given directly into a vein) antibiotic medication, and would return to facility. The Hospital emergency room Discharge Instructions, dated 10/09/20, documented the resident tested positive for UTI and COVID-19, and the physician ordered [MEDICATION NAME] (antibiotic) 500 milligrams (mg), by mouth twice a day for seven days. Review of the October 2020 Electronic Medication Administration Record [REDACTED]. The Communication with Resident/Family Progress Note, dated 10/21/2020 at 05:39 PM, documented staff advised R1's family member of R1's oxygen saturation level of 85% on 5 liters of oxygen via nasal cannula. The resident's family member requested the resident be transferred to the hospital for evaluation, and staff contacted the resident's physician who gave orders to send R1 to the hospital emergency room for evaluation. The Health Status Note, dated 10/22/2020 at 03:02 AM, documented the hospital staff reported R1 was admitted to the Intensive Care Unit for [MEDICAL CONDITION] (systemic infection of the blood), [MEDICAL CONDITION] (inadequate supply of oxygen) and COVID-19. The facility's Medication Orders, policy, dated 01/01/20, documented staff should administer medications upon signed order of a person lawfully authorized to prescribe. The documentation of Medication Orders should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order [REDACTED]. The facility failed to administer R1 a physician ordered antibiotic for UTI and COVID-19, placing the resident at risk for worsening infection and delayed healing.

The facility had a census of 34 residents. The sample included five residents with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to revised Resident (R) 5's care plan to include interventions to prevent the development or worsening of a facility acquired pressure ulcer. Findings included: - R5's Admission Minimum Data Set (MDS), dated [DATE], documented the facility admitted the resident on 09/14/20. The MDS documented the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of eight. The MDS documented the resident required extensive staff assistance with all activities of daily living (ADLs), at risk for pressure ulcers, and had no pressure ulcers. The MDS documented the resident had a pressure reducing device for chair and not on a turning/repositioning program. The Pressure Ulcer Care Area Assessment (CAA), dated 09/21/20, documented the facility admitted the resident with no pressure ulcer injuries and required staff assistance to complete ADL's. The ADL Care Plan, dated 09/18/20, documented R5 required one-two staff assistance to turn and reposition in bed. The Skin Care Plan, dated 09/18/20, documented the resident had potential/actual impairment to skin integrity related to fragile skin. The care plan directed staff to keep fingernails short, encourage good nutrition and hydration to promote healthier skin, follow facility protocols for treatment of [REDACTED]. The care plan documented the resident had skin tears on her right and left lower legs. The care plan lacked documentation the resident was at risk for pressure ulcers and interventions to prevent the development of pressure ulcers. The Admission Skin- Head to Toe Weekly Skin Checks, dated 09/14/20, documented the resident had several skin tears all over her body and severe [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) with drainage on all four extremities. The Braden Scale Assessment, (assesses risk for pressure ulcer development) dated 09/14/20, documented a score of 17, indicating at risk for pressure ulcers. The Skilled Nurse Note, dated 09/19/20, documented R5 had a skin tear on left arm and no other skin issues. The Braden Scale Assessment, dated 09/21/20, documented a score of 14, indicating moderate risk for pressure ulcers. The Skin- Head to Toe Weekly Skin Checks, dated 09/21/20, documented the resident had a 2.5 centimeter (cm) x 3.5 cm blister on her left buttock. On 11/03/20 at 02:19 PM, Administrative Nurse E stated R5's care plan did not have pressure ulcer interventions, but there should have been. On 11/04/20 at 03:03 PM, Administrative Nurse D stated she expected the care plan to address the risk for pressure ulcers and include interventions to prevent pressure ulcers. The Care Plan Revisions Upon Status Change policy, dated 01/02/20, documented a comprehensive care plan would be revised as necessary, when a resident experienced a status change. The nurse notified the MDS Coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team would discuss the resident's condition and collaborate on intervention options. The care plan would be modified as new or modified interventions. The unit manager or other designated staff member communicated care plan interventions to all staff involved in the resident's care. The facility failed to revise R5's care plan with interventions to prevent pressure ulcers, placing the resident at risk for pressure ulcers.

The facility identified a census of 35 residents. The sample included 14 residents, with 1 resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of 2 facility-acquired Stage II and unable to determine (UTD) pressure ulcers for 1 resident (#33). Findings included: - The physician's orders [REDACTED].#33 included [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive assistance of 1 staff with bed mobility and transfers. He/she ate independently. The assessment further indicated the resident was at risk for a pressure ulcer, did not currently have a pressure ulcer, and had a pressure-relieving mattress and wheelchair cushion. The 60-day MDS, dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The resident required extensive assistance of 1 staff with bed mobility and transfers, and he/she walked independently in his/her room. The assessment further indicated the resident was at risk for pressure ulcers, and had an unstageable pressure ulcer that was not present on admission. The Care Area Assessment for pressure ulcers, dated 11/01/17, revealed the resident was at risk for developing pressure ulcers. The care plan, dated 10/26/17, for potential skin integrity issues directed staff to educate the resident and family about causative factors and measures to prevent skin injury and for staff to provide a pressure-relieving mattress and pressure reducing cushion on the wheelchair. On 12/22/17, staff revised the care plan with documentation to float heels while in bed or recliner. On 12/22/17, staff revised the care plan with documentation of a suspected deep tissue injury on the left heel. On 1/3/18, staff revised the care plan with documentation of a Stage II pressure ulcer (a partial-thickness loss of skin with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) on the left lateral heel related to [MEDICAL CONDITION] (swelling in an arm or leg caused by a lymphatic system blockage). The care plan lacked new interventions after the development of a left heel pressure ulcer on 12/15/17, or after the development of a lateral left heel pressure ulcer on 1/2/18. The care plan further lacked documentation to place the resident in contact isolation precautions after 12/20/17, and interventions for the left heel wound infected with Staphylococcus aureus [MEDICAL CONDITIONS]. The care plan further lacked documentation of use of heel protectors or boots. The Braden Scale (an evaluation tool used to assess the resident's level of risk for development of pressure ulcers), dated 10/25/17, documented a score of 16, which indicated the resident was at mild risk for pressure ulcer development. The RN (Registered Nurse) Wound Assessment, dated 12/15/17, documented the left heel wound started on 12/15/17 as a blister with black color noted under the intact skin. Staff cultured the wound. The assessment lacked measurement of the left heel wound. The RN Wound Assessment, dated 12/17/17, documented the left heel wound measured 6.0 centimeters (cm) by 2.0 cm and had a strong, foul odor. The RN Wound Assessment, dated 12/22/17, documented the left heel wound measured 6.0 cm by 2.0 cm, had two small, dark areas, and was malodorous (smelling very unpleasant) with drainage noted that lacked description. Wound Data Collection, dated 12/29/17, documented the left heel wound measured 1.0 cm by 2.0 cm. The RN Wound Assessment, dated 12/29/17, documented the left heel wound had partial thickness loss, no odor, and the area was smaller in size. The RN Wound Assessment, dated 1/2/18, documented the medial left heel wound was very malodorous. The assessment lacked measurement of the medial left heel wound. The RN Wound Assessment, dated 1/2/18, documented a Stage II lateral left heel wound, which measured 1.0 cm by 1.0 cm. The wound had sloughing (dead tissue, usually cream or yellow in color) around the edges due to maceration (the softening and break down of skin resulting from prolonged exposure to moisture) related to weeping caused by [MEDICAL CONDITION]. Laboratory results, dated 11/29/17, recorded the resident's [MEDICATION NAME] as low at 3.1 grams per deciliter (g/dL), with the normal range as 3.5 g/dL to 5.5 g/dL. A laboratory report, dated 12/17/17 and noted by nursing staff on 12/20/17, documented the left heel had Staphylococcus aureus [MEDICAL CONDITION] ([MEDICAL CONDITION], a type of bacteria resistant to many antibiotics) isolated from the left heel wound. On 12/15/17, the facility faxed a clinical referral to the physician, which requested the physician examine the resident's left foot wound. Staff described the wound as a popped blister, with the area around the wound red and black in color under the loose skin of the blister. The facility also requested a physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The clinical record lacked documentation of the physician's treatment orders for the wound until 12/28/17. A nursing note, dated 12/18/17, documented staff set up an appointment for the wound clinic to evaluate the resident on 1/8/18. A nursing note, dated 1/2/18, documented staff notified the physician of a new Stage II pressure wound to the resident's left lateral heel, which measured 1.0 cm by 1.0 cm. A wound clinic note dated 1/8/18, documented the left heel (bottom) pressure ulcer measured 3.5 cm by 1.6 cm by 0.6 cm with yellow-brown slough, serosanguinous (containing or consisting of both blood and serous fluid) drainage, and the peri-wound had [DIAGNOSES REDACTED] (abnormal redness of the skin or mucous membranes due to capillary congestion), blanching (to take the color out of with application of pressure) and peeling. The note further documented the wound to the left heel developed due to the resident's foot resting on the back of the wheelchair foot pedal. A progress note, dated 1/8/2018, documented a physician's orders [REDACTED]. The note further documented staff had concerns the resident developed osteo[DIAGNOSES REDACTED] (an inflammation of bone caused by infection) due to the depth of the wound and the redness of the entire foot. The physician ordered Prevalon boots (heel protector boots designed to float the heel off the surface of the mattress) to both feet, to be worn at all times except when the resident ambulated. On 1/4/18 at 10:35 A.M., licensed nursing staff I entered the resident's room to change his/her left heel dressing. He/she removed Kerlix (a gauze dressing wrap) and a foam dressing from the resident's left heel. Observation revealed the resident had two open wounds on the left heel. Medial wound noted to be red with a flap of skin hanging down from the medial wound. The nurse did not measure the open areas, nurse I stated staff measured the wounds weekly. Licensed nursing staff I cleansed the wound with wound cleaner, applied [MEDICATION NAME] disc then covered with calcium alginate. Licensed nursing staff I held this in placed with his/her right hand, applied 4x4 gauze, held in place with Kerlix gauze, and secured with medical tape. Dry, red/brown drainage observed on the kerlix gauze removed from the residents' heel. The dressing applied was physician ordered on [DATE]. The dressing change observation revealed there currently was calcium alginate on the wound bed which was not ordered before that dressing change. On 1/8/18 at 12:01 P.M., the resident sat in his/wheelchair and his/her socked-foot rested directly on the foot pedal of the wheelchair. The resident did not have the Prevalon boots in place on his/her feet. On 1/9/18 at 11:06 A.M., the resident was out of the facility to an appointment. The resident's Prevalon boots remained in his/her room in a chair. On 1/4/18 at 11:00 A.M., licensed nursing staff I stated the resident had a wound on his/her left heel for about one month. He/she verified the wound was infected with MSRA. Licensed nursing staff I stated the resident was not on isolation precautions, but staff should wear gloves. He/she stated the precautions should be documented on the care plan. Licensed nursing staff I confirmed the care plan lacked documentation of [MEDICAL CONDITION] infections and appropriate isolation precautions. On 1/2/18 at 3:33 P.M., the resident stated he/she had a small blister on the bottom of his/her left heel that worsened. On 1/4/17 at 10:35 A.M., the resident stated he/she was not aware that he/she had two wounds on his/her left heel. On 1/4/18 at 11:00 A.M., licensed nursing staff I verified the dressing that he/she removed during the dressing change was not the dressing that the physician ordered. On 1/8/18 at 1:50 P.M., consultant physician KK stated he/she was aware of the resident's pressure ulcers, and stated staff should not have continued to apply a dressing to the wound without a physician's orders [REDACTED]. On 1/9/18 at 2:40 P.M., administrative nursing staff E verified the care plan lacked new interventions, such as the Prevalon boot. He/she indicated the care plan should have been updated. He/she stated MDS Coordinator, DON and Activities Coordinator are all able to add interventions to the care plan. On 1/9/18 at 4:00 P.M., administrative nursing staff D verified staff notified the physician of the resident's left heel wound on 12/15/17 and asked for treatment orders, but did not receive a response from the physician. He/she stated staff should have called the physician back the next day for a treatment order. He/she stated the wound was cultured on 12/15/17, and staff received [MEDICAL CONDITION] results on 12/19/17, but the dressing was not applied until 12/22/17. Administrative nursing staff D stated the resident should have had interventions in place to prevent the development of the wound. He/she confirmed staff did not offload the resident's heels to relieve pressure. On 1/9/18 at 4:00 P.M., consultant staff GG stated the facility had a protocol for staff to put a dressing in place on wounds, but he/she was unable to locate the physician's orders [REDACTED]. The facility's Pressure Ulcer policy dated 1/2017 documented the facility would use interventions to ensure a resident would not develop a pressure ulcer unless the resident's clinical condition demonstrated it was unavoidable. The policy further documented a resident who had a pressure ulcer would receive the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. The facility's Wound Dressing Change policy dated 10/2017 documented staff would complete dressing changes to promote wound healing and help the wound remain free of infection. The facility failed to develop and implement interventions to prevent the development of this resident's stage II pressure ulcer and pressure ulcer that was unable to determine (UTD) to his/her left heel, failed to develop and implement timely and effective interventions to promote healing and prevent deterioration of the wound, and failed to follow physician's orders [REDACTED]. ulcer, which [MEDICAL CONDITION] infection in this dependent resident.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to store and provide maintenance and housekeeping services necessary to maintain a sanitary and orderly environment in 1 of 1 facility kitchen, that provides meal service for the 35 residents who reside in the facility. Findings included: - On 1/05/2018 at 2:30 PM, during the initial tour of the kitchen, observation revealed the large and medium sized commercial mixers, located in the food preparation area, were not covered. On 1/09/2018 at 12:45 PM, during the follow up tour of the kitchen, observation revealed the fluorescent overhead lights above the food preparation area and above the dishwashing area, had numerous brown spots inside of the light covers and numerous spots of dried food debris and unknown brown substance on the outside of the light covers. Continued observation revealed the heating and air conditioning vent above the dishwashing area with condensation (moisture) on the metal grill and brownish gray dust particles coating the ceiling, approximately 3 inches by 4 inches on all 4 exterior metal panels on the ceiling vent. On 1/05/2018 at 2:40 PM, Dietary Staff BB verified the mixers were uncovered and staff should cover the mixers when not in use. On 1/09/2018 at 10:45 AM, Maintenance Staff U verified the florescent lights had debris on the outside of the light covers, was unsure what the substance was, and verified the dust particles on the ceiling in the dishwashing area and stated he/she cleaned the overhead lights and vents every 6 months. The facility 12/2017 kitchen cleaning schedule policy documented the policy is to promote a system that identifies cleaning tasks to be completed. The policy is to provide guidelines to employees for proper cleaning of kitchen immobile equipment. The dining manager is responsible for monitoring employees to ensure cleaning duties are completed in a satisfactory and timely manner. The policy ensured the staff would wipe up splashes on the walls and vents as soon as possible with a clean cloth and detergent and a scheduled thorough cleaning about every six months, or at a minimum annually. The ceilings are to be spot cleaned on an as needed basis. Sprinkler heads and ceilings will be thoroughly washed at a minimum of once per year. Check daily for cobwebs, dust and dirt or condensation so it cannot fall from the ceiling. The facility failed to store, prepare, distribute and serve food under sanitary conditions for the 35 residents residing in the facility who receive meals from the kitchen, placing the residents at risk for foodborne illness.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility's (QAA) Quality Assessment and Assurance program failed to provide adequate oversight to identify and prevent multiple quality issues of concern for the 35 residents, who reside in the facility. Findings included: - The facility failed to provide a toileting program that promotes dignity and quality of life for Resident #235. Refer to F550. The facility failed to provide necessary information to residents/beneficiaries, who received Medicare services, concerning continued services and financial responsibilities. Refer to F582. The facility failed to provide an assessment to accurately reflect the dental status of Resident #2. Refer to F641. The facility failed to update the care plan for Resident #85 after falls, Resident #235 for toileting and Resident #33 for pressure ulcers. Refer to F657. The facility failed to provide necessary assessment documentation, after a change in condition of respiratory status, for Resident #86. Refer to F684. The facility failed to provide necessary care and treatment to prevent the development of a pressure ulcer for Resident #33. Refer to F686. The facility failed to provide necessary services and assistance to maintain appropriate positioning in a Geri chair (upholstered recliner on wheels that provides positioning, comfort and mobility) for Resident #15. Refer to F688. The facility failed to follow care plan interventions and/or provide adequate supervision to prevent falls for Resident #85. Refer to F689. The facility failed to develop an appropriate toileting program for Resident #235. Refer to F690. The facility failed to ensure pain management for Resident #33. Refer to F697. The facility failed to provide necessary [MEDICAL TREATMENT] care and services for Resident #28. Refer to F698. The facility failed to provide nurse aide staff with the annually required 12 hour in-service education. Refer to F730. The facility failed to provide necessary dental services for Resident #2. Refer to F790. The facility failed to store, prepare and serve food in accordance with standards for food service safety. Refer to F812. The facility failed to ensure hospice assessment, care plan and services information were included in Resident #34's medical record. Refer to F849. The facility failed to maintain an infection prevention and control program to provide a safe, sanitary environment, to help prevent the development and transmission of communicable diseases and infections for Resident #33. Refer to F880. On 01/09/18 at 4:10 PM. Quality Assurance Staff E stated the facility's QAA meetings were held monthly and provided a sign-in sheet to verify the attendance of the medical director. Quality Assurance Staff AA stated the QAA committee had not identified all of the concerns addressed during the survey. The facility failed to identify, develop and implement appropriate plans of action to have an effective quality assurance and assessment program that identified and addressed the above issues involving multiple concerns, placing the 35 residents who reside in the facility at risk for mental, physical and psychosocial decline.

The facility had a census of 35 residents. Based on record review and interview, the facility failed to provide the resident (or their representative) the (ABN) Advanced Beneficiary Notice, Form CMS- for skilled services for 3 of 3 sampled residents. (#87, #2, #88) Findings included: - The Medicare ABN informed the beneficiary that Medicare may not pay for future skilled therapy services, and provided a cost estimate for continued services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed services. The facility lacked documentation Resident #87, or his/her representative, was provided an ABN form when the resident's skilled nursing services ended on 12/10/17. The facility lacked documentation Resident #2, or his/her representative, was provided an ABN form when the resident's skilled nursing services ended on 8/17/17. The facility lacked documentation Resident #88, or his/her representative, was provided an ABN form when the resident's skilled nursing services ended on 10/25/17. On 1/8/18 at 10:53 AM, Nurse Consultant GG stated staff provided the residents or their representatives the Notice of Medicare Non-Coverage and ABN forms but were unable to provide documentation the above residents received and signed the ABN forms. The (MONTH) (YEAR) facility SNF Beneficiary Notice Requirements Policy stated the liability notices were issued to notify Medicare Part A residents of their financial liability for services when skilled coverage criteria are not met. Forms issued are SNF Determination on Admission (GSS #925), must be issued on the day of admission when required, SNF Determination on Continued Stay (GSS# 926), must be issued at least 1 day prior to the last covered skilled day when required, and Advanced Beneficiary Notice (GSS#940), must be issued at least 1 day prior to delivering non-covered service/item. The facility failed to provide residents #87, #2 and #88 (or their representatives), the ABN form when discharged from skilled services, which placed the residents at risk to make uniformed decisions for their skilled services.

The facility identified a census of 35 residents. Based on observation, record review, and interview, the facility failed to prevent the development and transmission of infections when it failed to develop and implement interventions for a resident recently diagnosed with [REDACTED].#33). Findings included: - The physician's orders [REDACTED].#33 included [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitively. The resident required extensive assistance with bed mobility, transfers, and toileting. The care plan, dated 10/26/17, for potential skin integrity issues directed staff to educate the resident and family about causative factors and measures to prevent skin injury and for staff to provide a pressure-relieving mattress and pressure reducing cushion on the wheelchair. On 12/22/17, staff revised the care plan with documentation of a suspected deep tissue injury on the left heel. On 1/3/18, staff revised the care plan with documentation of a Stage II pressure ulcer (a partial-thickness loss of skin with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) on the left lateral heel related to [MEDICAL CONDITION] (swelling in an arm or leg caused by a lymphatic system blockage). Culture results of the left heel wound dated 12/17/17 documented the presence of [MEDICAL CONDITION] (MRSA - a type of bacteria resistant to many antibiotics). The clinical record lacked documentation to place the resident in isolation precautions after the resident's left heel wound became [MEDICAL CONDITION]. On 1/4/18 at 10:35 AM, staff discarded the old soiled wound dressing in a clear trash bag with other trash. Staff then took the trash bag and placed in the regular trash bin in the soiled utility room. The resident's door and doorway lacked signage to inform staff and visitors of isolation precautions. On 1/4/18 at 1:00 PM, the resident ambulated in the hall and wore non-skid socks on both feet. 01/09/18 at 3:30 PM administrative nursing staff E carried foam boots bare-handed from this resident's room down the hall to the soiled utility room. On 1/2/18 at 11:00 AM, licensed nursing staff I confirmed the culture obtained on 12/15/18 at the physician's office [MEDICAL CONDITION] in the resident's wound. Staff I further stated staff used gloves and followed contact precautions. Staff I further stated therapy changed the wound dressing for the resident at times, and they were expected to ask about any changes. On 1/4/18 at 10:28 AM, direct care staff Q reported he/she was just notified today of the resident's infection. On 1/8/18 at 3:07 PM, direct care staff N reported he/she received information about the resident'[MEDICAL CONDITION] a week or two ago. On 1/9/18 at 12:53 PM, housekeeping staff W reported his/her supervisor informed him/her about residents with infections. Staff W denied knowledge of any resident with an infection. On 1/9/18 at 1:52 PM therapy staff II denied knowledge the resident had an infection. On 1/9/18 at 1:52 PM, therapy staff JJ stated if a resident had an infection, he/she would wear gloves and followed the instructions posted. Staff JJ further stated he/she was not aware this resident had an infection. On 1/9/18 at 2:40 PM administrative nursing staff E reported direct care staff were able to access the care plan electronically and had the Kardex (a pocket-sized care plan) available for each resident, which included additional infection control measure for the resident. Staff E confirmed the Kardex [MEDICAL CONDITION] information for this resident. On 1-9-18 3:30 PM administrative nursing staff E reported the foam boots in the resident's room were no longer in use. On 1/9/18 at 4:00 PM administrative nursing staff D stated he/she expected staff to place the interventions [MEDICAL CONDITION] on the resident's care plan. Administrative staff D expected staff to put on gloves to carry foam boots and other contaminated resident equipment down the hall. He/she stated these items should be bagged once staff placed them in the dirty utility room. On 1/9/18 at 4:35 PM dietary staff BB reported administrative nursing staff informed him/her about residents with infections during the daily meetings. Staff BB further revealed he/she was not aware of a resident [MEDICAL CONDITION], but stated he/she was made aware of it on the morning of 1/9/18. The facility failed to implement interventions to prevent the spread of infection for this resident with [MEDICAL CONDITION] infection.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to ensure every nurse aide employed at the facility completed the minimum of 12 hours of in-service per year, and lacked a system for appropriately tracking nurse aide education. Findings included: - Review of the facility's nurse aide training records revealed 3 of the 15 (CNAs) Certified Nurse Aides, who were employed at the facility for at least a year, lacked completion of the minimum 12 hours of in-service required for certification. Review of the facility's CNA Training Hours Report lacked adequate tracking of the employees in -service hours in a timely and effective manner. On 1/10/2018 at 9:00 AM, Administrative Staff A stated he/she had not had adequate time to monitor the nurse aide continuing in- service hours, and stated he/she was aware the aides lacked adequate training hours. The facility's (MONTH) 2010 Annual Clinical Competency Review policy documented the facility would ensure staff have necessary skills to provide care and services to residents, and the facility would complete annual review of clinical skills for all nursing staff, including (CNA) Certified Nursing Assistant. The facility failed to ensure every nurse aide completed a minimum of 12 hours of inservice per year, and lacked an effective tracking system, placing the residents at risk for improper care and services.

The facility had a census of 35 residents. The sample included 14 residents. Based on record review and interview the facility failed to adequately monitor a respiratory change in condition, that resulted in a hospitalization , for 1 of 14 sampled residents. (#86) Findings included: - The 11/16/17 physician's orders [REDACTED].#86 had [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 11/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 14 (cognitively intact). The MDS also recorded the resident required extensive staff assistance with bed mobility and transfers, and was unable to walk. The MDS further recorded the resident had shortness of breath with exertion and lying flat, received oxygen therapy and used a ([MEDICAL CONDITION]) Continuous Positive Airway Pressure (positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who are not able to breathe spontaneously on their own). The 11/23/17 admission (CAA) Care Area Assessment for (ADLs) Activities of Daily Living function recorded the resident required extensive staff assistance with transfers and mobility, and received continuous oxygen therapy. The 12/07/17 care plan directed staff to provide continuous oxygen therapy, while the resident was awake, and [MEDICAL CONDITION] therapy, while the resident slept. The 12/15/17 at 10:47 PM, change in condition report documented staff assessed the resident with increased confusion, shortness of breath, and labored respirations. The change of condition report documented staff notified the physician and received orders to ensure the resident's oxygen was in place, continue to monitor the resident's respiratory status and notify the physician, if the resident's respiratory symptoms worsened. review of the resident's medical record revealed [REDACTED]. The 12/16/17 at 11:09 AM, late entry nurse's note recorded, at 7:00 AM, staff assessed the resident was weak and lethargic (drowsy, slow responsiveness), labored breathing with wheezes (hoarse, [MEDICATION NAME] sound that suggests respiratory distress), and diminished lung sounds. The note recorded staff assessed the resident's respiration rate at 24 per minute (normal rate 12 to 18) and oxygen saturation at 71% on 2 liters of oxygen (measure of how much oxygen the blood carries, normal levels are 95 - 100 % on room air). The nurse's note recorded staff notified the physician and received orders to send the resident to the emergency room . On 01/08/18 at 1:41 PM, Nurse G stated on 12/16/17, the night nurse reported the resident's change in condition at shift report and he/she assessed the resident immediately after report. Nurse G stated the resident continued to have increased confusion and respiratory problems, and he/she notified the physician and sent the resident to the emergency room , as ordered by the physician. On 01/08/18 at 2:57 PM, Administrative Nurse D stated nurses should assess the resident's change in condition, report to the physician as needed, follow the physician's orders [REDACTED]. The facility's Nursing Documentation Policy, dated 05/2017, directed nurses to document occurrences, health status assessments and changes in condition in a timely manner in the appropriate computer program. The facility failed to adequately monitor Resident #86's respiratory change in condition, that resulted in a hospitalization .

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to accurately assess a resident's status on the (MDS) Minimum Data Set assessment, for 1 of the 14 sampled residents. (#2) Findings included: - Resident #2's admission (MDS) Minimum Data Set assessment, dated 7/31/2017, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 14, which indicated no cognitive impairment. The assessment revealed the resident required limited assistance for personal hygiene, and had no oral/dental problems. The 7/31/2017 nutritional status (CAA) Care Area Assessment documented the resident had an order for [REDACTED]. The 10/25/2017 (ADL) Activities of Daily Living care plan directed staff to remind the resident to complete his/her oral care, documented the resident only had two teeth, and he/she was independent with oral care. The 7/25/2017 Nutritional Dietary Review documented the resident was able to eat independently, had 1 tooth on his/her upper gum, 1 tooth on the lower gum, and had an order for [REDACTED].>The 7/31/2017 oral/dental assessment documented the resident had two teeth remaining and appeared in good repair. The 10/04/2017 oral/dental assessment documented the resident had two bottom teeth. On 1/09/2018 at 10:20 AM, observation revealed the resident seated in a chair in his/her room. Further observation revealed Administrative Nurse E examined the resident's mouth with a pen light and revealed on the top left upper gum, the resident had 3 teeth which appeared broken off at the gum line. The front teeth had white nubs (a small lump) even with the gum line. The bottom gum had 1 tooth remaining on the left side with a gray, brownish discoloration around the base of the tooth, and a silver capped tooth. On 1/02/2018 at 3:17 PM, Resident #2 stated he/she had most of his/her teeth missing, the old dead tooth in the back was exposed, and sometimes he/she would get food, like potatoes chips, stuck in that tooth, which caused discomfort. The resident stated he/she did not want dentures at his/her age. Resident #2 verbalized it was hard to eat some of the food the facility served and he/she requested Rice Krispies a lot because it was easier to eat without pain and he/she could actually get it down. On 1/09/2018 at 1:00 PM Administrative Nurse E verified the resident had the above observed dental concerns and stated the admission MDS recorded the resident had no oral or dental problems, and was not correct. The Resident Assessment Instrument, user manual version 3.0, Section L- Oral and Dental Status, specific to the resident broken, carious and missing teeth lacked any documentation the resident had any dental concerns. The accuracy of the assessment means the appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies residents strengths to maintain or improve medical status, functional abilities and psychosocial status. The facility failed to accurately document Resident #2's broken, carious teeth on the admission MDS, placing the resident at risk for not receiving appropriate and effective dental care.

The facility identified a census of 35 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to update the care plan and revise as appropriate for 3 of 14 sampled residents, #33 for pressure ulcer care, #235 for toileting needs, and #85 after numerous falls. Findings included: - The clinical record documented resident #33 admitted to the facility on [DATE] with [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness, and swelling), candidiasis (fungal infection), xerosis cutis (rough, dry skin that may have scales or small cracks), and pruritis (itching). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive staff assistance with bed mobility and transfers. The assessment further documented the resident was at risk for a pressure wound, had no current pressure ulcer, and had a pressure-relieving mattress and wheelchair cushion. He/she was to have his/her feet floated when in bed or with his/her feet up. The Care Area Assessment for pressure ulcers, dated 11/01/17, revealed the resident was at risk for developing pressure ulcers. The care plan, dated 10/26/17, for potential skin integrity issues directed staff to educate the resident and family about causative factors and measures to prevent skin injury and for staff to provide a pressure-relieving mattress and pressure reducing cushion on the wheelchair. On 12/22/17, staff revised the care plan with documentation of a suspected deep tissue injury on the left heel. On 1/3/18, staff revised the care plan with documentation of a Stage II pressure ulcer (a partial-thickness loss of skin with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) on the left lateral heel related to [MEDICAL CONDITION] (swelling in an arm or leg caused by a lymphatic system blockage). The care plan lacked new interventions after the development of a left heel pressure ulcer on 12/15/17, or after the development of a lateral left heel pressure ulcer on 1/2/18. The care plan further lacked documentation to place the resident in contact isolation precautions after 12/20/17, and interventions for the left heel wound infected with Staphylococcus aureus [MEDICAL CONDITION] ([MEDICAL CONDITION] - a type of bacteria resistant to many antibiotics). The care plan lacked new pain interventions after the development of left heel pressure ulcer on 12/15/17, or after the development of a lateral left heel pressure ulcer on 1/2/18. On 1/8/18 at 1:50 PM, consultant physician KK stated he/she was aware of the resident's pressure ulcers, and stated staff should not have continued to apply a dressing to the wound without a physician's orders [REDACTED]. On 1/9/18 at 2:40 PM, administrative nursing staff E verified the care plan lacked new interventions and should have been updated. He/she stated the MDS Coordinator, administrative nursing staff D, and the Activities Coordinator were able to update the care plan. The facility's 9/2017 policy for comprehensive care plan and care conferences, documented the facility was to provide an ongoing method of assessing, implementing, evaluating, and updated the resident's care plan to help maintain the resident's highest level of functioning. The policy stated in addition to updates during a care plan review, care plans must be revised as the resident's needs/status changes. The facility failed to revise the care plan after Resident #33 developed a pressure wound on 12/15/17 and 1/2/18. - The physician's orders [REDACTED].# indicated a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident was frequently incontinent of urine and bowel. The resident required two-person physical assistance for toileting. The Care Area Assessment (CAA), dated 12/27/17, for urinary incontinence indicated the resident used a full lift and assistance of two persons to transfer to the toilet. The resident required more time to urinate and became incontinent when he/she could not get to the toilet to urinate. The resident asked for a bed pan to complete toileting needs. The resident denied incontinence prior to admission. The care plan dated 12/21/17 directed staff to encourage the resident to sit on the toilet to have a bowel movement. The care plan directed staff to observe, monitor, document, report to health care provided and signs or symptoms of complications related to constipation, change in mental status, new onset of confusion, swollen abdomen, vomiting, small loose stools, fecal smearing, bowel sounds, abdomen tenderness, guarding or rigidity. The care plan further documented the resident required two-person physical assist to the commode or with the bedpan. The care plan for bladder incontinence due to immobility and urgency directed staff to offer toileting every 2 hours while awake, at 1:00 A.M., 5:00 A.M., and as needed. On 1/9/18 at 4:00 P.M. administrative nursing staff D revealed staff completed an assessment of the resident's incontinence. Staff D further stated the resident may or may not alert staff when he/she needed to void. Staff D further stated staff would review the interventions on the care plan to ensure they were appropriate for the resident. The facility's policy for comprehensive care plan and care conferences, 9/2017 documented that the facility is to provide an ongoing method of assessing, implementing, evaluating and updated to the resident's care plan to help maintain the resident's highest level of functioning. The facility failed to revise the care plan to reflect Resident #235's accurate toileting plan for his/her current ability. - Resident #85's (POS) physician order [REDACTED]. shows it was untrue). The quarterly (MDS) Minimum Data Set assessment, dated 4/21/17, documented the resident had long and short term memory problems with moderately impaired decision making skills. The assessment revealed the resident required extensive assistance of 2 staff for transfers, toileting, ambulation in room, and extensive assistance of 1 staff for locomotion on and off the unit. The assessment further revealed the resident had 2 falls since the prior assessment. The quarterly MDS, dated [DATE], documented the same as the 4/21/17 MDS except the resident had 2 or more falls since the prior assessment. The quarterly MDS, dated [DATE], documented the same as the 6/9/17 MDS. The significant change MDS, dated [DATE], documented the same as the 6/9/17 MDS, except the resident had 1 fall since the prior assessment. The 12/2/17 (CAA) Care Area Assessment for falls recorded the resident was a high risk for falls and the resident often wandered or moved about in his/her wheelchair. The CAA further documented the resident had delusions and tried to walk. The 3/6/17, 5/9/17, and 9/7/17 care plan directed staff to toilet the resident every 2 hours while awake to prevent falls, and to not leave him/her in his/her room alone in the wheelchair. The updated 3/29/17 and 5/5/17 care plan directed staff to check the tabs alarm (patient safety alarm) during rounds, for placement, and to ensure it was working properly. The updated 5/22/17 care plan directed staff to check the resident's motion detector for placement and to ensure it was working properly each round. The 7/23/17 care plan update directed staff to assist the resident to bed between lunch and supper. The 8/22/17 care plan update directed staff to not place the resident alone in the commons area by the bird aviary. The updated 12/5/17 care plan directed staff to place the resident in a Broda chair (positioning chair) with an anti-thrust cushion (a cushion that eliminates forward sliding and sacral (a large triangular bone at the base of the spine) sitting problems). The 12/4/17, 9/14/17, 7/23/17 and 7/8/17 fall tool indicated the resident was a high risk for falls. The 4/26/17 at 3:11 PM, incident report documented staff found the resident on his/her knees on the floor in his/her room. The report documented the resident denied pain and had no injury. The 5/15/17 at 8:21 AM, incident report documented staff found the resident seated on the floor in his/her room, in front of his/her wheelchair. The incident report documented the resident tried to pick up pictures on the floor, denied hitting his/her head, and denied pain. Review of the care plan revealed no further interventions implemented to prevent further falls. The 5/28/17 at 1:01 PM, incident report documented staff found the resident on the floor in the dining room with his/her back against his/her wheelchair. Review of the care plan revealed no further interventions implemented to prevent further falls. The 6/4/17 at 5:53 AM, incident report documented staff found the resident in his/her room on the floor in front of his/her recliner. The incident report further documented the resident denied pain. Review of the care plan revealed no further interventions implemented to prevent further falls. The 6/26/17 at 2:00 PM, incident report documented staff found the resident on the floor in his/her bathroom and he/she stated, I was trying to go to the bathroom. The incident report further documented the resident denied pain and had no injuries. Review of the care plan revealed no further interventions implemented to prevent further falls. The 7/1/17 at 12:41 AM, incident report documented the resident was at the dining room table eating a snack with a staff member. The staff left the resident at the table, and the resident was observed by the nurse trying to stand up. The nurse told the resident to please sit down. The incident report further documented the nurse went to the medication cart and had his/her back toward the resident, and heard a big bang. The staff observed the resident lying on his/her left side and he/she complained his/her left arm and and leg hurt. The staff noted the resident's left leg was shortened, notified the physician, then called the ambulance to take the resident to the local hospital for X-rays. The resident returned to the facility and staff were notified the resident had no fracture or injury. Review of the care plan revealed no further interventions implemented to prevent further falls. The 7/2/17 at 6:15 AM, incident report documented staff found the resident on the floor in his/her bathroom and the resident reported he/she was trying to go to the bathroom. The incident report further documented no injury from the fall and the alarm had not sounded. Review of the care plan revealed no further interventions implemented to prevent falls. The 7/23/17 at 4:00 PM, incident report documented staff found the resident on the floor in his/her room, lying on his/her left side with his/her left arm and knee under him/her. The incident report documented the alarms had not sounded, the staff toileted the resident 30 minutes prior to the fall, and visually checked on him/her at 1:30 PM. The resident received a small scrape on his/her left knee. The 8/15/17 9:24 PM, incident report documented staff observed the resident on the floor, lying on his/her left side by the bird aviary. The incident report documented the resident was assessed with [REDACTED]. Review of the care plan directed staff not to leave the resident alone by the bird aviary, 7 days after the fall. The 9/14/17 at 7:28 PM, incident report documented staff found the resident seated on the floor in front of the doorway, shouting to go home. The resident was in his/her wheelchair and had removed his/her tabs alarm prior to trying to stand up. Staff assessed the resident for injury and noted the resident to have a small abrasion but staff did not indicate the location. Review of the care plan directed staff to assist the resident to bed between lunch and supper. The 10/21/17 at 1:09 PM, incident report documented staff found the resident on the floor in his/her room, seated in front of his/her wheelchair. The resident stated he/she was trying to get the pictures out of his/her drawer and slid out of the wheelchair. The incident report stated the resident was able to make needs known, knew how to use the call light system, and his/her alarms had not sounded. The resident received a small 0.4 (cm) centimeter x 0.05 cm scratch to his/her back. The care plan directed staff to make sure the resident's call light was in reach. On 1/8/18 at 12:07 PM, observation revealed Nurse Aide O assisted the resident to roll onto his/her right side, placed the hoyer lift sling underneath the resident, rolled the resident to the left side, and then back to his/her back. Further observation revealed Nurse Aide P attached the straps of the sling to the lift, raised the resident up, then Nurse Aide O guided the resident to the wheelchair, and Nurse Aide P lowered the resident into his/her wheelchair. On 1/8/18 at 12:30 PM, Nurse Aide O stated staff recently moved the resident closer to the commons area for staff to be able to monitor him/her better, because of his/her falls. Nurse Aide O further stated the staff placed a motion detector in his/her room because the resident liked to come in his/her room to look through his/her belongings. Nurse Aide O stated the nurse aides look at the residents care plan on the kiosk (a small stand-alone device providing information and services on a computer screen) or the nurses told them if there is anything special they need to do for the resident. On 1/9/18 at 3:30 PM, Administrative Nurse D stated staff should follow the resident's care plan and implement new interventions when the previous interventions are no longer effective. Administrative Nurse D stated the facility had a lot of at risk meetings for the resident and had recently changed the resident's wheelchair for a broda chair and that it had seemed to help with the resident's falls. Administrative Nurse A stated the resident should not be left unattended in the dining room because of increased risk for falls. Administrative Nurse D stated staff were aware to use the kardex (a medical-patient information system) and should know the interventions on the care plan, dash board (area on the computer system allowing staff to access information on specific residents) and kiosk, and the nurses were also aware of how to access the resident's care plan. The facility's 10/2017 Fall Prevention and Management Policy documented the care plan should be updated with any changes or new interventions, report to the state regulatory agency as appropriate, monitor the residents condition, and the effectiveness of the interventions. The facility failed to review and revise Resident #85's care plan, as needed, with appropriate and effective interventions to prevent the resident from further falls and injury.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide necessary services and assistance to maintain appropriate positioning in a Geri chair (upholstered recliner on wheels that provides positioning, comfort and mobility) for 1 of 14 sampled residents. (#15) Findings included: - The 01/08/18 physician's orders [REDACTED].#15 had [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 01/10/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 9 (moderately impaired cognition). The MDS also recorded the resident required extensive staff assistance with bed mobility and transfers, had impaired balance that required staff assistance to stabilize, and used a wheelchair for mobility. The 01/10/18 annual (CAA) Care Area Assessment for (ADLs) Activities of Daily Living function recorded the resident had limited mobility and impaired balance related to [MEDICAL CONDITION] and weakness. The 11/16/17 care plan recorded the resident lacked torso strength to maintain seated positioning and was at risk for pressure ulcer development related to immobility and leaning to the right. The care plan directed 2 staff to provide extensive assistance to reposition the resident and use a sling lift (supports full body) to transfer the resident. The 11/03/17 to 12/02/17 (OT) Occupational Therapy Evaluation and Plan of Treatment recorded the resident needed to improve sitting balance in his/her wheelchair to reduce risk for falls, improve comfort, and prevent skin issues. OT recommended the resident switch from a wheelchair to a Geri chair, to improve his/her positioning and safety needs. On 01/02/18 at 5:51 PM, observation revealed the resident, sat in a Geri chair, at the dining room table. Continued observation revealed the resident's torso and head leaned to the right, against and hanging over the armrest, and staff had not repositioned the resident. Continued observation revealed the resident ate his/her meal, while he/she continued to lean to the right. On 01/09/18 at 8:20 AM, observation revealed the resident, sat in a Geri chair, in his/her room. Continued observation revealed the resident's torso and head leaned to the right, against and hanging over the armrest, and staff had not repositioned the resident. Continued observation revealed staff served the resident breakfast, on an over-bed table, placed on the right side of the resident's Geri chair, and the resident ate his/her meal, while he/she continued to lean to the right. On 01/08/18 at 7:18 AM, Nurse H stated the resident required extensive staff assistance with repositioning and constantly leaned to the right in his/her Geri chair. Nurse H stated staff switched the resident from a wheelchair to a Geri chair several weeks ago, the Geri chair had no positioning devices, and he/she was not aware if therapy evaluated the resident's positioning in the Geri chair. Nurse H stated the resident refused to allow staff to reposition him/her at times, but staff should have attempted to reposition the resident before meals for his/her safety and comfort. On 01/09/18 at 9:18 AM, Nurse Aide M stated the resident was switched to the Geri chair several weeks ago and continues to lean to the right. Nurse Aide M stated the resident's Geri chair had no positioning devices and staff occasionally place pillows to reposition the resident. Nurse Aide M stated the resident ate and drank independently and staff should reposition the resident for better alignment at meals. On 01/09/18 at 11:10 AM, Therapy Staff JJ stated therapy evaluated and treated the resident for positioning in his/her wheelchair last month, and therapy switched the resident to a Geri chair to improve his/her positioning, safety, and comfort. Therapy Staff JJ stated therapy had not re-evaluated the resident's positioning since the switch to the Geri chair. Therapy Staff JJ stated staff should reposition the resident at meals for comfort and swallowing safety. On 01/09/18 1:38 PM, Nurse Consultant GG stated the resident was not able to reposition him/herself and had a history of [REDACTED]. Consultant Nurse GG stated therapy switched the resident from a wheelchair to a Geri chair several weeks ago, the resident had no positioning devices in his/her Geri chair, and therapy had not evaluated the resident's positioning in the Geri chair. The facility's 10/2017 Mobility and Positioning Policy directed staff to provide proper body alignment for residents, seated in a wheelchair, to prevent contractures (abnormal permanent fixation of a joint), skin issues, and improve comfort and function. The facility failed to provide necessary services and assistance to maintain appropriate positioning in a Geri chair for Resident #15, placing the resident at risk for decreased function and skin issues.

The facility identified a census of 35 residents. The sample included 14 residents, with 1 resident reviewed for urinary and bowel incontinence (inability to hold the urine or bowel movement). Based on observation, record review, and interview, the facility failed to treat the resident with respect and dignity when staff failed to develop and implement interventions to prevent incontinence for this resident who was dependent on staff for toileting. (#235). Findings included: - The physician's orders [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident was frequently incontinent of urine and bowel. The resident required two-person physical assistance for toileting. The Care Area Assessment (CAA, dated 12/27/17, for urinary incontinence indicated the resident used a full lift and assistance of two persons to transfer to the toilet. The resident required more time to urinate and became incontinent when he/she could not get to the toilet to void. The resident asked for a bed pan to complete toileting needs. The resident denied incontinence prior to admission. The care plan, dated 12/21/17, directed staff to encourage the resident to sit on the toilet to have a bowel movement. The care plan directed staff to observe, monitor, document, and report to the health care provider, any signs or symptoms of complications related to constipation, change in mental status, new onset of confusion, swollen abdomen, vomiting, small loose stools, fecal smearing, bowel sounds, abdomen tenderness, guarding or rigidity. The care plan further documented the resident required two-person physical assist to the commode or with the bedpan. The care plan for bladder incontinence due to immobility and urgency directed staff to offer toileting every 2 hours while awake, and at 1:00 A.M., 5:00 A.M., and as needed. The physician's orders [REDACTED]. The final culture report dated 12/29/17 noted Pseudomonas aeruginosa (a bacteria) present. A physician's orders [REDACTED]. On 01/3/18 at 9:58 AM, the resident stated he/she had not emptied out stool and felt he/she needed to sit on the toilet. The resident further stated he/she had not sat on the actual toilet since admission. On 1/4/18 at 3:47 PM, direct care staff Q stated he/she had never assisted the resident to the commode. Direct care staff Q further revealed the resident did better with bed pan, because the resident did not know when he/she must go to the bathroom. Direct care staff Q reported he/she looked at the care plan to know which toileting method to use for the resident. On 1/8/18 at 3:07 PM, direct care staff N stated the resident would tell staff when he/she needed to be changed. On 1/9/18 at 1:52 PM, consultant therapy JJ reported the resident was unable to tell when he/she had a bowel movement. On 1/9/18 at 4:00 PM, administrative nursing staff D revealed staff completed an assessment of the resident's incontinence. Staff D further stated the resident may or may not alert staff when he/she needed to void. The facility failed to treat the resident with respect and dignity when staff failed to develop and implement interventions to prevent incontinence for this resident who was dependent on staff for toileting.

The facility had a census of 46 residents. The sample included 6 residents with 1 resident reviewed for pressure ulcers. Based on observations, record review, and interview, the facility failed to provide care and treatment to prevent the development of a Stage II pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and to promote healing and prevent worsening, for a pressure ulcer. The facility failed to complete weekly skin assessments as planned and failed to apply a physician ordered dressing after the previous dressing had been removed. The resident's pressure ulcer worsened to a Stage III, for 1 of 1 resident reviewed. (#6) Findings included: - Resident #6's admission (MDS) Minimum Data Set assessment, dated 6/30/16, indicated the resident scored 5 on the (BIMS) Brief Interview for Mental Status, which indicated severe cognitive impairment. The MDS indicated the resident had behaviors not directed towards others, which significantly disrupted care or the environment. The MDS indicated the resident required extensive assistance of 2 staff for bed mobility, locomotion on/off unit, toileting, personal hygiene, total assistance of 2 staff for transfers, dressing, bathing, and extensive assistance of 1 staff for eating. The MDS indicated the resident was frequently incontinent of bladder, at risk for developing a pressure ulcer, but had no current skin issues. The MDS indicated the resident had a pressure reducing device for his/her bed and chair, on current turning/repositioning program and staff provided non-surgical dressing other than to his/her feet. The 6/24/16 Braden skin risk assessment revealed a score of 12-high risk. The 7/13/16 (CAA) Care Area Assessment for pressure ulcers indicated the facility admitted the resident with a healed pressure ulcer, which had a scab, and staff provided a pressure reducing device on the resident's bed/chair, and monitored the area. The CAA also indicated the resident was at high risk for pressure ulcers due to his/her poor mobility and urinary incontinence. The 6/24/16 pressure ulcer care plan indicated the resident was at risk for further skin breakdown due to urinary incontinence and decreased mobility. The care plan instructed staff to observe his/her skin during cares, and notify the nurse and resident's physician of noted skin breakdown. The care plan directed staff were to provide a pressure reducing device on his/her bed, wheelchair or recliner and the resident used incontinent products. The care plan instructed staff to use pillows/other positioning devices and to position on the resident's sides to keep pressure off his/her coccyx (tailbone).The 6/30/16 care plan update instructed staff to position the resident in his/her bed with a total lift and large sling and reposition the resident at least every 2 hours with 1-2 staff. The 7/31/16 care plan instructed the staff to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, discoloration, noted during the resident's bath or daily care. The 7/31/16 nursing assessment (first documented assessment of the wound re-opening) indicated the resident had a Stage II pressure ulcer on his/her coccyx, measuring 3.5 (cm) centimeters x 2.5 cm. Staff cleansed the area with wound cleanser, applied skin prep to the wound outer areas, and applied a clear Hydrogel (a gel in which the liquid component is water) dressing per physician's orders [REDACTED].>The 8/3/16 physician's orders [REDACTED]. The 8/5/16 at 4:23 AM, nurse's note indicated the (CNA) Certified Nurse's Aide notified the nurse the resident had an open area on his/her coccyx. The note indicated the nurse advised the CNA to apply barrier cream (cream used as protective skin barrier) to the area and the nurse would report the open area to the wound nurse. The 8/9/16 wound data collection form indicated the wound on the coccyx measured 2.5 cm x 1.3 cm with 1 cm depth, with 100% granulation (tissue formed during wound healing) tissue in the wound bed. The 8/11/16 physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. (8 days) The 8/18/16 wound data collection form indicated the coccyx pressure ulcer was a horizontal and vertical split that measured 1.5 cm x 1 cm, (smaller in size then the 8/9/16 measurements) with reddened tissue surrounding the open area to bilateral buttocks to rectum. The 8/29/16 wound data collection form (11 days later) indicated the coccyx pressure ulcer measured 0.6 cm x 0.6 cm with 0.1 cm depth with maceration (softening and breaking down of skin as a result from prolonged exposure to moisture) present at the site, 100% granulation tissue and minimal clear drainage. The 8/30/16 wound data collection form indicated the coccyx pressure ulcer measured 2 cm x 2 cm and no depth (increase in size from previous wound measurements 1 day prior) and 50% granulation tissue with slough (necrotic tissue separated from the living structure), minimal serosanguinous (semi-thick reddish) drainage. The form indicated the wound was larger than last week and no Stage of the wound documented. The 9/8/16 physician's orders [REDACTED]. (same treatment as physician ordered on [DATE]) The 9/8/16 physician's orders [REDACTED]. The 9/9/16 wound data collection form indicated the resident's pressure ulcer on his/her coccyx measured 2.7 cm x 1.5 cm had no depth, and slightly bigger than last week. The dressing was present/intact, with an odor noted to the wound bed, and a moderate amount of purulent (producing or containing pus) drainage. The wound contained 25% [MEDICATION NAME] tissue (membranous cellular tissue that covers a free surface or lines a tube or cavity), 10% granulation tissue, 25% slough and eschar (dead tissue) and no Stage of the wound documented. The 9/23/16 wound data collection form indicated the resident's Stage II pressure ulcer measured 2 cm x 1.7 cm and 0.1 cm in depth with 75% granulation tissue and 25% slough tissue. The 9/27/16 physician's orders [REDACTED]. bed and cover with an [MEDICATION NAME] (all-in-one dressing for fluid handling) dressing, which was to be changed every 3rd day and as needed. The 9/30/16 wound data collection form indicated the resident's Stage II pressure ulcer on his/her coccyx measured 3.1 cm x 2.0 cm (increase in size from 9/23/16 measurements) with no dressing in place and wound bed had 90% slough and 10% redness with moderate amount of serosanguinous drainage, increased redness, swelling around the wound, increased drainage and maceration to wound edges. The form indicated the wound had increased in size. The 9/30/16 at 11:51 AM, nurse's notes indicated staff notified the physician of the resident's dressing being off. The resident's physician instructed staff to continue to monitor the resident's wound. The 10/6/16 facility investigation stated the staff removed the resident's dressing to his/her coccyx pressure ulcer on 9/28/16 around 11:00 AM and agency Nurse C had not applied a physician's orders [REDACTED]. The investigation revealed the resident had no dressing on his/her pressure ulcer at 10:00 AM on 9/29/16. The investigation revealed the resident had an unstageable pressure ulcer on his/her coccyx and the physician directed staff to change the dressing every 3 days. The investigation revealed a (CNA) Certified Nurse Aide informed Nurse C of the resident's soiled dressing that staff removed on 9/28/16 around 11:00 AM. Nurse C told the CNA to get the resident up without a dressing for lunch and the facility remained uncertain if the dressing was off until 9/29/16. On 10/3/16 a written verification e-mailed to the facility by Nurse C stated he/she administered the residents' noon medications in the dining room when a CNA approached him/her and informed him/her, the staff would be getting Resident #6 up for lunch if the nurse wanted to do the resident's wound care on his/her coccyx at that time. The note indicated Nurse C checked the resident's (TAR) treatment administration record and he/she was unable to find a current wound treatment order. Nurse C explained to the CNA he/she was unable to find a treatment order for the wound and Nurse C needed to discuss the order with Nurse D. Nurse C instructed the CNA to go ahead and get the resident up for lunch which the CNA stated he/she would do. Nurse C indicated he/she had tried several times to locate Nurse D between 12:00 PM and 2:00 PM and was unable to locate the wound nurse before his/her shift was over. Nurse C stated he/she was unsure of the dressing order for the resident's pressure ulcer or how often the dressing was to be changed. Nurse C stated he/she was not assigned to the hall the resident resided on and needed to verify the resident's wound orders. Nurse C stated he/she did pass on at shift change he/she had not completed the resident's pressure ulcer treatment and would need to discuss the order with Nurse D and the order needed to be added to the resident's TAR. The 10/4/16 written verification received from Nurse E stated when he/she came on shift on 9/28/16 he/she was asked to relieve Administrative Nurse F from administering the residents' 6:00 PM medications. Nurse E asked Administrative Nurse F if he/she could give Nurse E a shift report prior to Administrative Nurse F leaving. Nurse E stated he/she did not receive a shift report on the residents in the facility from Administrative Nurse F. The 10/6/16 notarized witness statement from Nurse D stated a CNA came to Nurse D and voiced Nurse C refused to apply a new dressing to Resident #6's coccyx pressure ulcer, due to Nurse C unable to find a physician's orders [REDACTED]. The statement indicated the CNA got the resident up as instructed by Nurse C. The statement indicated staff informed Nurse D at approximately 11:30-11:45 AM on 9/28/16. Nurse D notified Administrative Nurse F at approximately 12 noon about the dressing not being applied as Nurse D was working in a different area in the facility that day. The 10/7/16 wound data collection form indicated the resident's coccyx pressure ulcer was now a Stage III (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia) with minimal serous drainage. The 10/8/16 physician's orders [REDACTED]. Review of the October 2016 (MAR) Medication Administration Record [REDACTED]. On 10/13/16 at 8:25 AM, observation revealed Nurse D and Nurse G positioned the resident on his/her right side to perform a dressing change to the resident's pressure ulcer on his/her coccyx. Nurse D measured the wound at 1.8 cm x 1.5 cm and 0.1 cm in depth. The wound bed appeared dark pink and moist. Nurse D provided the physician ordered dressing change, cleansed the area with wound cleanser, applied Thera honey to the wound bed and covered with [MEDICATION NAME] dressing. The 10/13/16 wound data collection form indicated the resident's coccyx pressure ulcer measured 1.8 cm x 1.5 cm with 0.1 cm in depth with moderate serosanguinous drainage, and 100% granulation tissue. On 10/17/16 at 4:47 PM, Nurse J stated the resident did not have a pressure ulcer on his/her coccyx on admission. Nurse J stated staff turned the resident every 2 hours and also checked and changed the resident due to his/her bowel and bladder incontinence. On 10/18/16 at 11:10 AM, Nurse D verified the resident's pressure ulcer on his/her coccyx worsened from a Stage II to a Stage III (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia). On 10/18/16 at 12:51 PM, Administrative Nurse A verified Resident #6's pressure ulcer worsened, since the dressing was not reapplied on 9/28/16, as ordered. The facility's 9/2012 pressure ulcer practice guidelines policy indicated residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition. Any abnormal findings/changes (redness, rashes, bruises, open areas) should be reported to the licensed nurse assigned to the resident for assessment and follow-up. The facility failed to perform weekly skin assessments, wound measurements, and physician ordered dressing changes to Resident #6's coccyx pressure ulcer as needed, when the prior dressing became soiled. This caused the resident's Stage II pressure ulcer, which was open to air, for approximately 24 hours, to progress to a Stage III level pressure ulcer and increase in size, develop slough, and eschar tissue in the wound bed, placing him/her at increased risk for pain and infection.

The facility had a census of 56 residents. The sample included 18 residents of which 3 were reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of pressure ulcers for 3 of 3 residents sampled for pressure ulcers, Resident #27, who developed a deep tissue injury (a pressure related injury to subcutaneous tissues under intact skin), Resident #34, who developed a facility acquired Stage III pressure ulcer (an open area that extends into the tissue beneath the skin, forming a small crater, fat may show in the sore but not muscle, tendon or bone) and Resident #16, who developed a facility acquired Stage II pressure ulcer (topmost layer of skin is broken, creating a shallow open sore and fluid leakage may or may not be present). Findings included: - Resident #34's annual (MDS) Minimum Data Set assessment, dated 2/25/16, indicated the resident's cognition was not assessed. The assessment further indicated the resident required extensive assistance of one staff for bed mobility, toileting, and supervision with no staff assistance with transfers, walking, dressing, and personal hygiene. The assessment indicated the resident was not at risk for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), had no pressure ulcers, and no preventative measures in place to prevent pressure ulcer development. The 14 day MDS assessment, dated 3/26/16, indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 13, required limited assistance of two or more staff for walking, and required extensive assistance of two or more staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. The assessment further indicated the resident was at risk for pressure ulcers, had a deep tissue injury, and had a pressure reducing device for his/her chair, nutrition or hydration intervention to manage skin problems, received pressure ulcer care, and received application of dressings to feet. The 2/25/16 (CAA) Care Area Assessment for pressure ulcers indicated no concern for pressure ulcers, the resident was usually independent with mobility but became ill and required more assistance due to weakness related to his/her illness. The CAA for nutrition, dated 2/25/16, indicated the resident ate and drank well and there were no concerns with nutrition. The 12/17/15 and 3/10/16 care plans did not address pressure ulcers. The 3/11/16 care plan indicated the resident required limited to extensive assist of 1 to 2 staff for bed mobility. The 3/29/16 care plan indicated the resident had the potential for pressure ulcer development related to poor mobility and stated the resident will have intact skin, free of redness, blisters or discoloration by the next review date. The care plan directed staff to educate the resident and family on causes of skin breakdown, instructed staff to turn and reposition the resident at least every 2 hours, provide a pressure relieving/reducing cushion on the wheelchair, skin protective boots on both feet and heels, keep heels off the bed with supportive pillows, and immediately notify the nurse of any new areas of skin breakdown. The 3/30/16 care plan update indicated the resident had 1 deep tissue pressure ulcer and the pressure ulcer will show signs of healing and remain free from infection through the next review date. The care plan instructed staff that Prevalon boots (pressure reducing boots worn on the feet/heels) were to be worn at all times. Review of the medical record revealed the resident had a recent hospitalized from [DATE] through 3/9/16. The 3/1/16 Braden Scale for Predicting Pressure Sore Risk (a tool used by nursing staff that uses a scoring system to evaluate a person's risk of developing a pressure ulcer. The total score can range from 6-23, with a lower score indicating a higher risk for pressure ulcer development) revealed a score of 22, indicating the resident was not at risk for developing pressure ulcers. The 3/9/16 Braden Scale score was 18, indicating the resident higher at risk for developing pressure ulcers. The 3/9/16 at 11:00 AM, Nursing Re-Admit Data Collection assessment indicated the resident was independent with toileting, dressing, transferring, and ambulation prior to his/her most recent illness and hospitalization . The assessment further stated skilled services were to be provided to attempt to decrease the resident's level of care, as it had been prior to his/her hospitalization . The assessment described the resident's feet as warm, dry and intact with swelling located in both lower extremities. The assessment further stated the resident's skin integrity was normal, warm, dry, with normal skin turgor (an assessment used to determine fluid loss or dehydration), and no arterial ulcers, diabetic ulcers, traumatic wounds, surgical wounds,[MEDICAL CONDITION] suspected deep tissue injuries present upon readmission to the nursing facility. The 3/16/16 at 9:32 PM, nurse's note indicated the resident received Tylenol 650 (mg) milligrams for complaints of bilateral (both sides) pain in his/her feet and nursing staff would monitor for pain. The 3/17/16 at 10:19 AM, dietary note indicated the resident received a regular diet, was able to eat independently, ate his/her meals in the dining room, and had a 5% weight loss in the last 30 days. The 3/17/16 at 1:55 PM, nurse's note indicated the resident voiced complaints of left foot pain and the left foot was swollen and hot to the touch. The note further indicated the resident required assistance of 2 staff members. The 3/18/16 at 1:23 AM, nurse's note indicated the resident complained of tenderness to the bottoms of his/her feet and nursing staff would monitor. Review of the medical record from 3/16/16-3/18/16 revealed no skin assessment of the resident's heels. The 3/20/16 at 10:28 PM, nurse's note indicated the resident ate less than 50% of the evening meal. The 3/21/16 Wound Assessment indicated the resident had a deep tissue injury to his/her left heel that measured 2 (cm) centimeters in length by 3.5 cm in width. The wound assessment revealed the wound was not present on readmission, the wound bed was 100% eschar (a dry, dark scab or falling away of skin) with pink, intact skin surrounding the wound. The 3/21/16 at 4:22 PM, nurse's note indicated staff sent a fax to the resident's physician in regards to the resident's left heel deep tissue injury, and the right outer foot had an intact superficial abrasion. The note further indicated nursing staff were waiting for a return fax with orders for treatment to the resident's feet. The 3/21/16 (untimed) fax to the physician regarding the deep tissue injury, indicated the nursing staff had initiated Prevalon boots on at all times and dressing order changes to apply skin prep to the heel, then foam dressing. The fax requested the physician's response to the proposed orders. The 3/23/16 physician's orders [REDACTED]. The 3/28/16 Wound Assessment indicated the resident's left heel deep tissue injury measured 6 cm length by 5 cm width, the wound bed was not described, but the surrounding skin pink and intact. The 3/29/16 physician's orders [REDACTED]. The 4/6/16 at 3:14 PM, dietitian assessment indicated the resident received a regular diet and his/her intake was 75-100%. The note further indicated the resident had a left heel deep tissue injury, with skin surrounding the heel was pink and intact at the time of the assessment, and the resident received [MEDICATION NAME], twice daily, to promote healing. The 4/12/16 physician's orders [REDACTED]. The 4/18/16 wound assessment indicated the resident's left heel deep tissue injury measured 4 cm length by 6 cm width, the wound bed was not described. The 5/18/16 at 12:02 PM, physician's orders [REDACTED]. On 5/17/16 at 1:33 PM, observation revealed the resident, seated in his/her wheelchair, with both feet resting on the foot pedals of the wheelchair. The resident wore slippers with a non-skid sole, an open heel with a small lip that extends approximately 1.5 cm up the back part of the heel. Resident was not wearing Prevalon boots. On 5/17/16 at 2:18 PM, observation revealed Administrative Nurse G removed the resident's slipper and socks from his/her left foot and two pinpoint sized, shallow dents were present to the outer side of the heel. Further observation revealed Administrative Nurse G cleansed the left heel with wound cleanser, did not apply skin prep prior to application of a 3 inch by 3 inch foam dressing and wrapped the left heel and ankle with gauze. On 5/18/16 at 5:10 PM, observation revealed the resident in his/her room, seated in a wheelchair, with his/her feet resting flat on the floor. The resident wore the same slippers as observed on 5/17/16. On 5/19/16 at 11:08 AM, observation revealed the resident in his/her room, seated in a wheelchair and wearing tennis shoes. On 5/19/16 at 2:00 PM, (CNA) Certified Nurse Aide N stated he/she was not sure what kind of care the resident required and the resident did not need staff help on that day. On 5/19/16 at 2:04 PM, CNA K stated when the resident came back from the hospital in March, he/she was completely dependent on staff, the resident was weak and had stayed in bed a lot and hardly ever got up. CNA K further stated the resident had improved since then and was completely independent, but he/she was pretty sure the resident had Prevalon boots to wear. On 5/19/16 at 2:10 PM, CNA O stated he/she did not know anything about the resident's heel and had no knowledge of a pressure ulcer. On 5/17/16 at 2:23 PM, Administrative Nurse G stated the resident wore a Prevalon boot at all times for awhile, but now had slippers that he/she wore during the day and Prevalon boots at night (during time of the interview, the resident did not have a physician's orders [REDACTED]. On 5/18/16 at 6:10 PM, Licensed Nurse I stated when the resident came back from the hospital on [DATE], the resident was weak and staff would reposition him/her up in bed and he/she would slide back down with his/her feet resting on the footboard. Licensed Nurse I stated the staff obtained a body pillow to elevate the resident's feet and that he/she was not sure if the resident wore Prevalon boots all the time. Licensed Nurse I verified the physician's orders [REDACTED]. On 5/19/16 at 4:32 PM, Licensed Nurse R verified the resident had a decline in many areas of his/her activities of daily living and the care plan for the deep tissue injury was not updated until several days after staff discovered the wound. On 5/19/16 at 6:35 PM, Administrative Nurse A stated when the resident came back from the hospital he/she was not in bed, except for at bedtime. Administrative Nurse A further stated he/she felt the deep tissue injury had probably started while the resident was in the hospital and that it wouldn't have hurt to have pressure ulcer prevention interventions in place prior to the resident developing a deep tissue injury. Administrative Nurse A verified the documentation lacked assessment of the resident's heels when he/she complained of foot pain. The facility's Pressure Ulcers policy, revised 9/2012, stated the following: based on the resident's comprehensive assessment, the center will use prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates the pressure ulcer was unavoidable. The policy further stated, when detecting skin injury, regardless of skin color, nursing staff should be able to detect localized heat over an area of localized inflammation and prevention strategies should be developed and implemented at the time of admission based on the initial assessments of the causative factors that contribute to the resident's risk for skin breakdown. Prevention strategies, should be ongoing and will be individualized based on the areas or the level of risk determined. The policy directs staff to include these prevention strategies on the resident's care plan, inform caregivers of the prevention strategies, ensure the competence of caregiver implementation of the care giver, and to observe or demonstrate if necessary. The facility failed to assess the resident's heels and initiate interventions for Resident #34, who returned from the hospital with a risk for pressure ulcer development due to a decrease in mobility, as evidenced by an increase in need for staff assistance with activities of daily living, a decrease in Braden Scale Pressure Sore Risk, and complaints of foot pain. - Resident #16's physician order [REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 12/14/15, indicated the resident usually understood and sometimes understands, the cognition was not assessed, and the resident required extensive assistance of 2 staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS further indicated the resident was always incontinent of bladder, occasionally incontinent of bowel, at risk for developing pressure ulcers, on a turning/repositioning program and had a pressure reducing device for chair. The 12/14/15 nutritional status (CAA) Care Area Assessment stated the resident was on a pureed diet and allowed soft moist pleasure foods which are easy to chew. The resident was seen by speech therapy to determine the best action and doing well on the diet plan. The 12/14/15 pressure ulcer CAA stated the resident had no skin issues due to pressure or moisture at the time and was at risk due to immobility and incontinence. The quarterly MDS, dated [DATE], indicated the resident had short and long term memory problems, moderately impaired cognition, and a Stage II pressure ulcer acquired on 1/12/16. The MDS further indicated the resident had a pressure reducing device for chair and bed, was on a turning/repositioning program and received pressure ulcer care. The 3/10/16 care plan directed staff to reposition the resident every 2 hours while in bed and chair for pressure redistribution, provide a pressure reducing cushion in wheelchair and contained no direction to staff regarding skin care for the resident ' s pressure ulcer discovered on 1/12/16. The 1/12/16 Braden Scale for Predicting Pressure Ulcer risk revealed a score of 14, which indicated the resident at moderate risk for developing pressure ulcers. Review of the January 2016 treatment record indicated staff completed a skin assessment every Saturday and the treatment record contained staff initials on 1/9/16 with no documentation of the resident's skin condition. The 1/12/16 at 1:51 PM nurse's notes revealed hospice staff informed the facility that resident #16 had a skin issue on his/her back. The 1/12/16 wound data collection form revealed a pressure ulcer to the right mid back which measured 0.9 (cm) centimeters x 1.1 cm, the wound bed was dark brown, and surrounding tissue intact and red. The Concern/Grievance form, dated 2/26/16, indicated the resident was left in the recliner all night, staff were aware the resident had a pressure ulcer on his/her back, and the resident was saturated with urine when the staff assisted the resident up from the recliner in the morning. Review of the wound data collection forms dated 2/22/16 and 2/29/16 revealed the following measurements of the resident's pressure ulcer on his/her back: 2/22/16 1.5 cm length x 1.5 cm width x 0.2 cm depth. 2/29/16 2 cm length x 2 cm width x 0.2 cm depth (which revealed the wound had increased in size after he/she was left in the recliner overnight). Review of the 5/11/16 Wound Data Collection form (4 months after discovery of the wound) revealed the resident's pressure ulcer measured 2 cm x 1.5 cm x 0.1 cm. On 5/18/16 at 12:04 PM, observation revealed Resident #16 seated in a high back wheelchair with the pressure ulcer area on his/her back resting directly against the back of the wheelchair. On 5/18/16 at 3:14 PM, observation revealed Nurse H and I entered the resident ' s room with supplies for a dressing change. Observation revealed the resident lying on his/her right side (side of pressure ulcer area) with no pressure relief devices around the resident ' s pressure area. Nurse H removed the dressing and revealed a reddish purple area approximately golf ball size pressure ulcer area with a 2 cm x 2 cm open area in the middle, and a pink wound bed. Nurse H cleansed the wound with wound cleanser and a gauze pad, applied hydrogel silver on dressing, and applied the dressing to the wound. On 5/18/16 at 3:55 PM, observation revealed Resident #16 seated in a high back wheelchair at the dining room table with the pressure ulcer area on his/her back resting directly against the back of the wheelchair. On 5/18/16 at 5:35 PM, observation revealed Resident #16 seated in a high back wheelchair at the dining room table awaiting supper with the pressure ulcer area on his/her back resting directly against the back of the wheelchair. On 5/18/16 at 6:25 PM, observation revealed Resident #16 assisted from his/her wheelchair into a recliner with the pressure ulcer area on his/her back resting directly against the back of the recliner. Continued observation revealed the staff had not repositioned the resident since 3:55 PM (2 hours 30 minutes). On 5/19/16 at 7:24 AM, observation revealed Resident #16 lying on his/her right side (the pressure ulcer area) with no pillows around the resident's pressure ulcer area on his/her back. On 5/19/16 at 7:50 AM, observation revealed Nurse Aide J and K entered Resident #16's room and assisted him/her out of the bed and into his/her high back wheelchair with the resident's pressure ulcer area on his/her back resting directly against the back of the wheelchair. On 5/19/16 at 9:04 AM, observation revealed Resident #16 was assisted by staff from his/her wheelchair into a recliner with the resident's pressure ulcer area on his/her back resting directly against the back of the recliner. On 5/19/16 at 12:09 PM, observation revealed Hospice Aide W and Nurse I assisted the resident from the recliner into his/her high back wheelchair with the resident's pressure ulcer area on his/her back resting directly against the back of the wheelchair. Continued observation revealed the staff had not repositioned the resident since 9:04 AM (3 hours). On 5/18/16 at 4:43 PM, Therapy Staff P stated, on 3/1/16, therapy staff completed an evaluation for wheelchair positioning, and recommended a high back wheelchair for the resident's kyphotic posture (round back, a condition which the spine in upper back has excessive curvature). Staff P was unaware the resident had a pressure ulcer on his/her right middle back. On 5/19/16 at 8:15 AM, Nurse Aide J stated staff are to reposition the resident while he/she is in the recliner, wheelchair and bed and use pillows in the bed to keep the resident off of his/her right side. On 5/19/16 at 12:40 PM, Administrative Staff S verified the resident was left in the recliner all night and the resident had a pressure ulcer on his/her back at that time. Administrative Staff S verified the recliner does not have any cushion where the resident's pressure ulcer area rests against the recliner or wheelchair. On 5/19/16 at 3:02 PM, Nurse Aide L stated it was his/her third day on the job, he/she was not aware Resident #16 was on a 2 hour turning/repositioning program and had a pressure ulcer on his/her back. Nurse Aide L provided a pocket care plan which had no direction to the staff for Resident #16's turning program or skin conditions. On 5/19/16 at 3:04 PM, Nurse Aide M stated he/she was an agency aide and did not know Resident #16. Nurse Aide M stated he/she would rely on the facility aide and he/she did not know where the facility aide was at the present time. On 5/19/16 at 3:20 PM, Nurse Q stated a few days before the hospice staff alerted the facility of Resident #16's pressure ulcer, a nurse aide alerted him/her of a reddened area on the resident's shoulder. Nurse Q stated he/she looked at the resident's upper shoulder but did not remove the resident's shirt and look at the entire shoulder area. Nurse Q stated the resident would roll to his/her right side. On 5/19/16 at 3:56 PM, Nurse Aide O stated the staff reposition the resident every 2 hours and usually tilt the resident toward the wall on his/her right side which has the pressure ulcer area. On 5/19/16 at 4:58 PM, Nurse G stated Resident #16 liked to lay on his/her right side in the bed and the facility did not use anything for positioning or pressure relief when the resident was seated in the recliner or wheelchair. On 5/19/16 at 6:45 PM, Administrative Nurse A stated Resident #16's pressure ulcer was acquired in the facility and therapy evaluated him/her for the new wheelchair and therapy should have seen the resident had a disfigured back and needed something for pressure relief. On 5/23/16 at 3:29 PM, Physician T verified the resident's pressure ulcer would not heal until the pressure was relieved from the area. The facility's Pressure Ulcer Prevention Strategies policy, dated 9/2012, directed staff to collaborate with restorative nursing and therapy staff for residents presenting with positional challenges. The facility failed to develop and implement effective interventions to prevent the development of pressure ulcers for Resident #16, who developed a Stage II facility acquired pressure ulcer. - Resident #27's quarterly (MDS) Minimum Data Set Assessment, dated 4/1/16, indicated the resident sometimes understands others, and had a (BIMS) Brief Interview for Mental Status score of 7 indicating severe cognitive impairment. The MDS revealed the resident totally dependent on staff for transfers and required extensive assistance for bed mobility. The MDS further revealed the resident had no extremity impairment, at risk for pressure ulcers, had unhealed pressure ulcers, and one Stage 3 pressure ulcer, measuring 2.2 x 2.9 x 0.3 (cm) centimeters. The MDS revealed the resident had pressure reducing devices for the bed and chair, on a turning/repositioning program, had nutrition or hydration interventions to manage skin problems, pressure ulcer care, and application of dressings to feet. The quarterly MDS, dated [DATE], indicated the resident had no unhealed pressure ulcers, had (MASD) moisture associated skin damage, and had no pressure reducing device in bed. The resident's (CAA) Care Area Assessment for Pressure Ulcers, dated 1/1/16, indicated the resident had an actual Stage 3 pressure ulcer. The resident was a total lift with all transfers and required extensive assistance with all cares. The resident required a lot of encouragement and prompting for eating and sometimes needed assistance. The 4/14/16 care plan revealed the resident had impairment to skin integrity on the left medial foot related to poor mobility and shearing potential evidenced by a history of an open area on the coccyx and history of right heel and skin breakdown on bilateral buttocks, the dietician was consulted related to skin breakdown issues. The care plan instructed staff to refer the resident to the wound clinic as needed and keep the resident's skin clean and dry. The care plan instructed a licensed nurse to perform weekly skin assessments and instructed staff to apply pressure reducing boots bilaterally while in bed. The care plan indicated the resident had a potential for pressure ulcer development related to limited mobility, weakness, and inability to reposition self. The care plan instructed staff to assist the resident to turn/reposition at least every 2 hours and (PRN) as needed, and to provide a pressure relieving/reducing cushion in his/her wheel chair. The 7/27/15 medical record indicated the resident had a Braden scale (scale to determine risk for pressure ulcers) score of 13, indicating the resident was at risk for pressure ulcers. The 10/27/15 medical record indicated the resident had a Braden scale score of 13, indicating the resident was at risk for pressure ulcers. The 1/26/16 medical record indicated the resident had a Braden scale score of 12, indicating the resident was at risk for pressure ulcers. The 3/29/16 medical record indicated the resident had a Braden scale score of 14, indicating the resident was at risk for pressure ulcers. The dietician assessment note, dated 1/7/16, indicated the resident received treatment to a Stage 3 area to left medial foot and received a multivitamin daily and [MEDICATION NAME] (nutritional supplement to promote wound healing) (BID) twice a day to promote healing. Continue with interventions. The dietary profile note, dated 4/10/16, indicated the resident was on a mechanically altered therapeutic diet. The note indicated the resident had a left medial foot pressure sore, right lateral foot/abrasion, and sacrum redness. The 2/10/16 Physician order [REDACTED]. The 10/8/15 (WCN) wound clinic note indicated the resident had a Stage 3 (PU Pressure Ulcer to the left medial foot metatarsal measuring 1.1 cm x 1.5 cm x 0.2 cm. The 10/19/15 WCN - Stage 3 PU to the left medial foot metatarsal measuring 1.2 cm x 1.8 cm x 0.2 cm. . The 11/2/15 WCN - Stage 3 PU to left medial foot metatarsal, 1st toe measuring 1.1 cm x 1.5 cm x 0.1 cm. The 11/12/15 WCN - Stage 3 PU to the left medial foot metatarsal measuring 1.3 cm x 2 cm x 0.1 cm. The 12/1/15 WCN - Stage 3 PU to the left medial foot metatarsal measuring 2.1 cm x 3 cm x 0.1 cm. The 12/10/15 WCN - Stage 4 PU to the left medial foot metatarsal measuring 1.5 cm x 2.3 cm x 0.7 cm. The 12/21/5 WCN - Stage 4 PU to the left medial foot metatarsal measuring 1.8 cm x 2.0 cm x 0.3 cm. The 1/7/16 WCN - Stage 4 PU to the left medial foot metatarsal measuring 1.8 cm x 2.0 cm x 0.3 cm. The 1/25/16 WCN - Stage 4 PU to left medial, 1st, foot metatarsal measuring 1.8 cm x 2.0 cm x 0.3 cm. The 2/4/16 WCN - Stage 4 PU to left medial, 1st, foot metatarsal measuring 1.8 cm x 1.7 cm x 0.3 cm. The 1/13/2016 4:57 nurse's note indicated staff informed the nurse the resident had a sore on the right foot. This nurse assessed the resident, and noted a 2 cm x 1 cm abrasion, applied (TAO) Triple Antibiotic Ointment and foam to the area, and notified the (PCP) Primary Care Physician via fax with treatment recommendations. The 2/25/16 WCN - Stage 4 PU to his/her left medial,1st, foot metatarsal measuring 2.5 cm x 2.5 cm x 0.2 cm, a sore to the right lateral foot 5th toe measuring 2 cm x 1.4 cm x 0.1 cm. The Physician Note/Orders indicated 1) abrasion of right foot. The ulceration of right foot started out as abrasion to the foot. It now appears to have been compromised by continued pressure. It is imperative to wound healing that patient be positioned in such a way that there is NO pressure to either foot wounds. They have deteriorated significantly since last visit. Decubitus ulcer of left foot, Stage 4 - greatly deteriorated since last visit. Imperative patient wear Prevalon boots at all times and be positioned for pressure relief of wounds. 2) Decubitus ulcer of left foot, stage 4; Greatly deteriorated since last visit. Will change local wound care to daily Santyl Imperative patient wear Prevalon boots at all times and be positioned for pressure relief of wounds. The 3/24/16 WCN - Stage 3 PU to left medial foot, 1st, metatarsals measuring 2.4 cm x 2 cm x 0.2 cm, a sore to the right lateral foot measuring 2 cm x 2.9 cm x 0.1 cm, The Physician Note/Orders indicated a decubitus ulcer of left foot, stage 4, and a decubitus ulcer left metatarsal, stage 3. The 4/7/16 at 12:58 PM nurses note indicated staff faxed the physician regarding reddened areas to the resident's bony areas on his/her right medial foot and left lateral foot. The 4/11/16 WCN - Stage 3 PU to left medial foot, 1st, metatarsals measuring 3.6 cm x 2 cm x 0.3 cm, a sore to the right lateral foot 5th toe measuring 2 cm x 2.5 cm x 0.3 cm, a sore to the right foot medial first toe measuring 1.5 cm x 1.5 cm x 2 cm, a sore to the left foot medial 5th toe measuring 0.6 cm x 0.5 cm x 2 cm. The Physician Note/Orders indicated an abrasion of right foot, decubitus ulcer of left foot, stage 4, the wounds are worse due to multiple factors including age, probable protein deficiency despite supplements, and pressure despite off-loading and Prevalon boots. Care may most likely be palliative at this point given lack of progress in existing wounds and appearance of new wounds despite intervention. Will continue following in the wound care clinic to prevent further deterioration and infection. A decubitus ulcer left metatarsal, stage 3. The 5/19/16 WCN - Stage 3 PU to left media foot, 1st, metatarsal measuring 1.8 cm x 0.8 cm x 0 cm, a sore to right lateral foot measuring 0.9 cm x 2.1 cm x 0.4 cm, a sore to left medial foot, 5th toe measuring 0.3 x 0.4 x 0.1 cm, a sore to the right medial foot measuring 1.9 cm x 2.3 cm x 0 cm, a sore to left lateral foot measuring 0.2 cm x 0.2 cm x 0 cm. The Physician Note/Orders indicated 1) Non-healing ulcer of foot with necrosis of muscle, 2) Decubitus ulcer of right foot, stage 4, 3) Decubitus ulcer of left foot, stage 4, 4) decubitus ulcer left metatarsal, stage 3. The 9/3/15 medical record indicated the resident's [MEDICATION NAME] (protein made by the liver) level was 3. Normal range 3.5-4.8 g/dL. On 5/18/16 at 7:50 AM, observation revealed the resident seated in his/her geri-chair, both feet wrapped in bandages with Prevalon boots (pressure relieving protection to relive heel pressure) on feet bilaterally. At 8:25 AM staff brought a plate of scrambled eggs, ground sausage, and pureed french toast with syrup to the resident . Observation revealed the resident ate all of his/her meal. After finishing at 9:00 AM, staff assisted the resident to the shower room for his/her whirlpool. On 5/18/16 at 9:35 AM, observation revealed resident seated in a whirlpool chair lift. Administrative Nurse G comes entered the shower room to assess and redress resident's wounds. Administrative Nurse G placed wound supplies on a blue absorbent pad under the resident's feet, sprays a gauze 4 x 4 with wound cleanser and wipes the resident's left medial foot from the resident's arch to his/her toes. Administrative Nurse G then obtains a clean gauze 4 x 4 pad and sprays it with wound cleanser to and wipes the left outer side of the foot, up to the toes, and between the 4th and 5th toes, then covers the same areas with skin sealant. Administrative Nurse G charges his/her gloves and uses hand sanitizer between each treatment done on the different areas of each foot. Administrative Nurse G then cuts a 1.5 cm square of Collagen Silver and places it between the 4th and 5th toes on the left foot. Administrative Nurse G then u

The facility had a census of 55 residents of which 10 resided in the Special Care Unit. The sample included 3 of the 10 resident who resided in the special care unit. Based on observation, record review and interview, the facility failed to provide an environment free from abuse for 1 of 3 sampled residents. (#2) This failure placed Resident #2 in immediate jeopardy Findings included: - Resident #2's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 6 which indicated severely impaired cognition. The assessment revealed the resident independent with ambulation, had steady balance, no behaviors, and did not wander. The 2/18/16 care plan stated the resident had impaired cognitive function, sometimes associated with agitation. The care plan further stated the resident needs supervision with all decision making and directed staff to cue, reorient and supervise as needed. The 3/29/16 at 6:37 PM, nurse's note stated staff notified the nurse to come to the (SCU) special care unit as soon as possible. The note stated an incident had occurred between Resident #2 and another resident. The note further stated the resident did recall being hit and pushed down and asked the nurse if he/she was bleeding. The resident had a small abrasion (scrape) to his/her left chin area with slight bleeding. The note stated the resident had been wandering in and out of other residents' rooms prior to the incident and wandered in to Resident #1's room when the physical fight started. On 3/31/16 at 2:00 PM, observation of the facility video, of the incident, revealed Resident #2 wandering down the hall in the SCU and into Resident #1's room and no staff visible. Further observation revealed Resident #1 pushed Resident #2 out of his/her room which caused Resident #2 to stumble and fall against the wall across the hallway. Resident #1 kicked Resident #2 while he/she was on the ground. As Resident #2 stood up, Resident #1 hit Resident #2 repeatedly with his/her open hand. Resident #1 continued to hit Resident #2 repeatedly and Resident #2 was unable to protect him/herself. Continued observation of the video revealed an unsampled resident, in the SCU slowly ambulating towards the two residents fighting in the hallway. The unsampled resident stopped, then walked around the two residents without incident. Observation revealed Resident #1 and Resident #2 talking to one another, then Resident #1 hit Resident #2 in the head again. Resident #2 turned around and walked down the SCU hall and stands by the nurse's station. Continued observation of the video revealed the residents unsupervised and no staff in the area. Resident #1 walked toward the couch in the commons area of the SCU and starts to sit down but notices Resident, #3, sitting in his/her favorite recliner. Resident #1 walks towards Resident #3 and at that time Nurse Aide C enters the area, and stands between Resident #1 and Resident #3. Continued observation revealed, Nurse Aide C walked over to Resident #2 and calls to Nurse Aide D who ran down the hall and out of the SCU doors. The POS, dated 2/16/16, indicated Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5 day MDS, dated [DATE], indicated the resident had long and short term memory problems with modified independence in decision making skills. The assessment revealed the resident independent with ambulation, had disorganized thinking, inattention, delusions, verbal behaviors towards others, rejection of care and wandered. The assessment further revealed the resident received daily antipsychotic and antidepressant medication and antianxiety medication, 1 day during the 7 day look back period. The 1/21/16 care plan stated Resident #1 had impaired cognitive functions and poor decision making skills. The care plan further stated the resident had behavior symptoms due to dementia, a previous altercation with another resident and directed the staff to intervene as necessary to protect the rights and safety of others. (although the facility video revealed no staff supervision at the beginning or during the physical fight between Resident #1 and Resident #2 on 3/29/16) The 2/16/16 physician's orders [REDACTED]. Review of the medical record revealed the facility had administered the [MEDICATION NAME] twice in the month of March, once on the 15th and, once on the 16th. The 3/29/16 at 7:00 PM, nurse's note stated there had been an physical altercation between Resident #1 and Resident #2 after Resident #2 went into Resident #1's room. The note stated Resident #1 pushed Resident #2 out of his/her room and Resident #2 fell to his/her knees. Resident #1 began slapping Resident #2 in the face several times with an open hand. The note further stated Resident #1 kicked at Resident #2 and proceeded to hit Resident #2 more. The note stated Resident #1 went over to Resident #3 who was sitting in a recliner and Resident #1 pulled Resident #3 out of the recliner. The note further stated the 6:00 PM shift arrived and the (DNS) director of nursing services informed them of the altercation between the two residents and directed the nurse coming on duty to administer, [MEDICATION NAME] (an antipsychotic medication) intramuscularly, as ordered by the physician to Resident #1. The note stated the DNS contacted the resident's physician who directed him/her to send the resident to a neighboring hospital for evaluation. The note stated the facility called the hospital and informed the (ER) emergency room staff of Resident #1's current and past resident to resident altercations and requested ER to evaluate Resident #1. The physician at the hospital stated the resident would be sent back to the facility if he/she did not display any behaviors. The note stated the resident started swinging at the nurse and refused the [MEDICATION NAME] injection so staff did not administer it. The DNS then directed a staff member to drive the resident to the hospital for evaluation but the resident refused numerous times. Multiple staff attempted to persuade the resident to go but he/she refused. The note stated the resident, while seated at the dining room table, took a metal butter knife and started to cut at the chair and then rubbed it on his/her sweats. The note stated the DNS called the local law enforcement for assistance in encouraging the resident to go for a ride in the van. Review of the medical record revealed the facility sent the resident to the hospital on [DATE] and he/she had not returned as of 3/31/2016. On 3/31/16 at 2:45 PM, observation revealed Resident #2 independently ambulating in the commons area. Further observation reveled a small scabbed area on the left side of his/her chin. On 3/31/16 at 10:35 AM, Nurse Aide D stated he/she had been in the whirlpool room with the door closed and did not see or hear the incident between the Resident #1 and Resident #2. Nurse Aide D stated when he/she left the whirlpool room, he/she observed a coworker talking to Resident #2 and noted the scrapes on Resident #2's face. Nurse Aide D stated he/she was not aware of the physical altercation until viewing it on the facility video. On 3/31/16 at 11:53 AM, Nurse Aide C stated he/she was assisting a resident in his/her room with the door closed, when he/she heard Resident #2 yelling but did not go out to check on him/her because the resident had been yelling off and on during the day. Nurse Aide C stated he/she did not see the incident between the two residents and did not know what had happened until viewing the incident on the facility video. On 3/31/16 at 1:00 PM, Administrative Nurse A stated there are two staff members that work the SCU and stated there should always be one staff member on the floor at all times. Administrative Nurse A stated the two staff members that were working in the unit were unaware of the incident until he/she showed them the incident on the facility's video. The 9/13 facility Abuse and Neglect Policy stated the resident has a right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, or volunteers. The facility failed to adequately supervise and prevent a physical altercation between Resident #1 and Resident #2, who sustained facial abrasions. The facility abated the immediate jeopardy on 4/7/16 after completion of training of all staff regarding utilizing the stop and watch program to send alerts to nurses regarding resident behaviors. The staff also received training regarding the facility's abuse and neglect policy, and reviewed behavioral causes and intervention training. The facility appointed a Special Care Unit Coordinator, and will round with the geri-psych physician to discuss behaviors occurring on the unit. The Social Service designee will monitor behaviors daily documented by the nurse aide, and the Director of Nursing will monitor behaviors documented by nurses. The deficient practice was abated to a scope and severity of a G.

The facility had a census of 60 residents. The sample included 3 residents, of which all were reviewed for accidents. Based on observation, interview, and record review the facility failed to provide supervision and assistive devices to prevent accidents for 2 of 3 residents reviewed for falls. Resident #1 fell while unattended in the bathroom and sustained a frature. Resident #2 required medical treatment and evaluation at the emergency room after a fall from his/her wheelchair and required sutures. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 12/10/15, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 11, and exhibited no behaviors. The MDS further indicated the resident required limited assistance from 1 staff for bed mobility, transfers, walk in room/corridor, dressing, toilet use, and personal hygiene. The MDS stated the resident had an unsteady balance, was only able to stabilize with staff assistance, used a walker, had a fall prior to admission to the facility, and received insulin and antianxiety medication. The fall (CAA) Care Area Assessment, dated 12/10/15, indicated the resident had a history of [REDACTED]. The CAA further indicated the resident had orthostatic hypotension (low blood pressure when moving from sitting to standing position), [DIAGNOSES REDACTED] vertigo (a spinning sensation caused by changes in the position of the head), and required standby assistance with all transfers and ambulation with a walker and a gait belt. The 12/4/15 care plan informed staff the resident had impaired visual function related to being legally blind and a [DIAGNOSES REDACTED]. The care plan instructed staff to maintain the resident's room arrangement to promote independence. The 12/21/15 care plan review informed staff the resident had an (ADL) Activities of Daily Living self care performance deficit related to weakness and activity intolerance and required standby by assistance with toileting. The 12/23/15 care plan review instructed staff the resident at risk for falls related to healing of cracked ribs evidenced by a history of falls, and to encourage the resident to participate in activities that promote exercise and physical activity. The 1/22/16 care plan review instructed staff to provide a personal alarm to alert staff to the resident's movement. The 2/4/16 care plan review instructed staff to assess the resident as indicated for a significant change in cognition, safety awareness and decision making capacity. The 12/3/15 hospital discharge instructions indicated the hospital staff provided fall prevention education to the resident prior to discharge, and indicated the resident's activity required assistance from staff as tolerated with a walker. The 12/3/15 fall risk assessment indicated the resident a high risk for falls. The 1/19/16 facility fax to the physician revealed staff found the resident on the floor, and he/she had a bump on his/her head. The staff asked the physician if a personal alarm could be implemented, and on 1/20/16, the physician responded yes. The 1/19/16 at 1:26 AM, facility fall investigation indicated the resident missed his/her bed when he/she sat down, and the resident consistently does not use the call light. The investigation revealed staff provided a personal care alarm. The 1/20/16 at 9:30 PM, nurse's note indicated the resident is alert and used the restroom with assistance of 1 staff, complained of light headedness when standing up from the chair, his/her balance is unsteady, and he/she needed to take a minute for the light headedness to diminish after standing. The 1/31/16 at 11:00 AM, nurse's note indicated the resident forgets to use the call light to get up. The 2/4/16 at 12:01 AM, facility fall investigation indicated staff left the resident unattended on the toilet, and the resident got up off the toilet without assistance, attempted to sit on his/her walker, and missed. The 2/4/16 at 12:01 AM, nurse's note indicated the resident had a weak right hand grip, had a laceration to the ulna (the thinner and longer of the two bones in the human forearm, on the side opposite to the thumb) side of his/her wrist, and radial (bone extending from the elbow to the wrist on the side opposite to the thumb) side of wrist was swollen. The note indicated the resident's wrist looked to be offset, and staff called 911 for (EMS) emergency medical services to transport the resident to the emergency room to evaluate and treat. The 2/4/16 radiology report indicated the resident had a significantly displaced fracture of the distal right radial metaphysis (wrist) and a fracture with some impaction of the distal right ulnar shaft (wrist). The 2/4/16 emergency room report indicated staff evaluated the resident and treated him/her for closed fracture of the right radius and ulna, and instructed staff to keep the sugar tong splint (a medical device used to stabilize a fractured limb) on, at all times except for bathing and clothes changing. On 3/10/16 at 8:16 AM, observation revealed the resident, seated on the side of his/her bed without any shoes or slip resistant socks, dressed in pajamas, and with his/her call light activated. At 8:20 AM, observation revealed Nurse L entered the resident's room and asked if he/she needed assistance, and the resident responded he/she needed to use the bathroom. Further observation revealed Nurse L began to assist the resident with standing with the walker, than he/she stopped, and asked the resident if he/she used a walker to ambulate. The resident responded yes, Nurse L began to assist the resident to stand again, and than stopped stating he/she needed a gait belt. Observation revealed Nurse Aide K entered the room and Nurse L asked if he/she needed a gait belt, Nurse Aide K replied yes, and went to find one. Nurse Aide K returned to the room with a gait belt and Nurse L asked if the resident required assistance with 1 or 2 staff. Nurse Aide K replied 1, and stated he/she could finish the transfer. Further observation revealed Nurse aide K applied the gait belt, noted the resident did not have on shoes, and assisted the resident to put on his/her shoes. Nurse Aide K assisted the resident to stand, and the resident ambulated to the bathroom with the Nurse Aide K and his/her walker. On 3/3/16 at 12:50 PM, Medication Aide C stated, on 2/4/16 at approximately 11:30 PM, the resident was not in bed, and was still in his/her recliner. Medication Aide C verified he/she assisted the resident to the bathroom to get ready for bed, and a call light sounded 2 doors down. Medication Aide C further verified the resident had gotten up from the toilet and had fallen while he/she was assisting the other resident. Medication Aide C stated he/she told the resident to stay on the toilet and he/she would be right back. Medication Aide C stated he/she had thought a motion alarm was in place, but verified he/she had not checked to know if it was functioning and turned on. Medication Aide C further verified he/she would not have left the resident on the toilet if he/she had known the motion alarm was not in place, and a resident who required a personal alarm should not be left unattended on the toilet. On 3/3/16 at 10:02 PM, Nurse D verified the resident had an increase in confusion, and had attempted several times to sit when nothing was underneath him/her. Nurse D further verified a motion alarm would not have alarmed if the resident stood up in the bathroom without assistance. Nurse D verified when staff notified him/her the resident fell , his/her assessment of the resident revealed a weak grip strength and the resident's right wrist was limp. On 3/10/16 at 10:40 AM, Nurse Aide A stated some days the resident was fine, and other days he/she would need more assistance and would forget to call for assistance. Nurse Aide Aide A further stated once the resident started having falls staff recognized he/she had a decline and was not safe to be independent. On 3/10/16 at 10:40 AM, Nurse Aide B stated if a resident had a personal alarm, staff should not leave the resident unattended on the toilet. On 3/10/15 at 2:30 PM, Administrative Nurse E verified staff should not leave the resident unattended on the toilet due to a recent decline, multiple falls, and he/she required a personal alarm. The facility's 7/2015 Fall Prevention and Management policy indicated an avoidable accident occurred when staff failed to implement interventions, including adequate supervision consistent with the resident's needs, goals, and plan of care. The policy further indicated a root cause analysis is used to identify root cause of faults or problems to analyze falls. The facility failed to provide adequate supervision for Resident #1 who fell when left on the toilet unattended and sustained a wrist fracture. - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 10/30/15, indicated the resident had severely impaired cognition with short and long term memory problems, and moderately imaired decision making skills. The MDS further indicated the resident had inattention and disorganized thinking behaviors. The significant change MDS, dated [DATE], indicated staff had not assessed the resident's cognition or behavior portion of the assessment. The MDS indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and always incontinent of bladder. The MDS revealed the resident had a less than 6 month prognosis, 2 or more non injury falls in the look back period, and received antippsychotic (medication to treat psychosis), antidepressant, and antibiotic medications. The fall (CAA) Care Area Assessment, dated 12/14/15, informed staff the resident had recent falls, had poor safety awareness related to poor vision, poor hearing, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, and poor mobility. The CAA further indicated the resident was dependent on staff for all transfers and repositioning, is not ambulatory, hollers out and does not use the call light when he/she needs assistance. The 11/5/15 care plan informed staff the resident was at risk for falls related to syncope (dizziness) dementia (progressive mental disorder characterized by failing memory, confusion), and weakness, evidenced by a history of falls and poor decision making. The care plan instructed staff to apply the alarm to the head of bed when the resident is lying down, and to provide an anti roll system to the resident's wheel chair. The care plan further instructed staff to place the bed in the lowest position, place a lip mattress on the bed, and a mat to the floor. The 11/30/15 care plan update instructed staff to review new or progressive neurological impairments. The 12/19/15 care plan update instructed staff to provide a personal alarm to alert staff to the resident's movement and to assist staff in monitoring the resident. The 2/26/16 care plan update instructed staff to monitor the resident for significant changes in positioning in his/her wheelchair, and mobility. The 11/11/15 at 2:10 PM, facility fall investigation indicated staff found the resident on the floor, yelling, hey come here. The note indicated the resident was next to the fall mattress and the alarm was not sounding. The note further indicated staff had not attached the alarm when they placed the resident in the bed. The 12/19/15 at 6:40 AM, facility fall investigation indicated the resident slid off of his/her bed, and staff was unable to get to him/her in time after the alarm sounded. Review of the investigation revealed no root cause analysis. The 12/24/15 at 10:50 AM, facility fall investigation indicated the resident scooted him/herself onto the fall mattress. The investigation indicated the resident had a low bed, scoop mattress, fall mat, and the personal alarm was working and in place. Review of the investigation revealed no root cause analysis. The 2/26/16 at 12:14 PM, nurse's note indicated staff called the physician's office and notified the office nurse of the resident's rising temperature and complaints of pain and weakness. The 2/26/16 physician's orders [REDACTED]. The 2/26/16 at 6:55 PM, nurses note indicated staff heard a loud boom and saw the resident on the floor, and blood visibly noted on the right side of his/her head. The note indicated the resident stated his/ her head hurt, staff called the physician, and he/she instructed staff to send the resident to the emergency room for evaluation and treatment. The 2/26/16 facility fall investigation indicated the resident leaned forward in his/her wheelchair and fell on to the floor. The investigation indicated the resident had an earlier temperature of 99.6, and started on Levaquin. The investigation further indicated the resident was more anxious than usual, and yelled for help even with 1:1 supervision. The investigation further revealed staff notified the Hospice nurse of the fall on 2/29/16, (3 days later) and he/she recommended an evaluation of the resident's wheelchair to prevent tipping. The investigation stated the resident's right forehead was bruised and had stitches noted in a horseshoe shape. The investigation further stated the Hospice nurse encouraged staff to alter the wheelchair or provide a new wheelchair to promote resident safety. The 2/26/16 hospital documentation indicated the emergency room treated the resident for a laceration repair with sutures, and a closed head injury. On 3/3/16 at 11:00 AM, observation revealed the resident sitting in a recliner in the commons dining area of the facility, slightly leaning to the right, yelling someone help me. Further observation revealed the resident has a large healing bruise to his/her right forehead and steri strips in place. On 3/3/16 at 4:00 PM, observation revealed the resident sitting in a regular wheel chair, with anti tip bars placed in the back of the wheelchair. Further observation revealed the resident propelling him/herself independently throughout the facility. Observation revealed the resident would bend over at the waist, leaned to the right, and attempted to open locked doors. Further observation revealed the resident continued to propel around the facility leaning to the right, without staff intervention, and would yell periodically somebody help me. On 3/3/16 at 10:02 PM, Nurse D verified the day the resident fell from his/her wheelchair, staff stated he/she had been leaning more than usual, and staff adjusted him/her several times. Nurse D verified he/she was unsure what was put into place to prevent falls from his/her wheelchair, and he/she still used the same wheelchair. On 3/10/16 at 8:13 AM, observation revealed the resident sitting in a highback wheelchair at the dining room table, being assisted by staff with his/her morning meal. Further observation revealed the resident not slumped over, and in a proper position. On 3/10/16 at 9:19 AM, Nurse Aide F stated the resident seemed much more comfortable in his/her new highback wheelchair. On 3/10/16 at 11:00 AM, Nurse Aide H stated the resident has a curved spine, and has a hard time sitting up. Nurse Aide H stated the day the resident fell from his/her wheelchair he/she was yelling all the time, and rolling around in his/her wheelchair. Nurse Aide H verified the resident leaned a lot that day, and staff just kept pulling him/her up in the wheelchair. On 3/10/16 at 11:53 AM, Nurse I verified the day the resident fell from the wheelchair he/she appeared more tired, almost exhausted, and leaned over a little more. Nurse I verified staff did not do anything to assist the resident with his/her posture other than readjust him/her in the wheelchair, which was not effective. Nurse I stated staff did not notify him/her the resident was leaning, and did not attemp to transfer the resident to something safer than his/her wheelchair. On 3/10/16 at 1:46 PM, Dietary Staff J stated he/she was not surprised the resident fell from his/her wheelchair because of the way he/she was leaning that evening. Dietary Staff J stated the resident kept leaning forward, and staff would straighten him/her up, but he/she just kept leaning forward. On 3/10/16 at 2:06 PM, Nurse Aide G stated the evening the resident fell from his/her wheelchair, the resident was hunched over more than usual. Nurse Aide G stated he/she assisted the resident to reposition in the wheelchair multiple times, but the resident would go right back to being hunched over. Nurse Aide G verified he/she did not attempt to transfer the resident out of his/her wheelchair. On 3/10/16 at 3:30 PM, Administrative Nurse E verified the resident was weak from an infection, and staff should have notified the nurse of his/her problems with positioning in the wheelchair. The facility's 7/2015 Fall Prevention and Management policy indicated an avoidable accident occurred when staff failed to implement interventions, including adequate supervision consistent with the resident's needs, goals, and plan of care. The policy further indicated a root cause analysis is used to identify root cause of faults or problems to analyze falls. The facility failed to provide adequate supervision and assistive devices for Resident #2, who fell from his/her wheelchair, and sustained a head laceration which required sutures at the hospital.

The facility had a census of 55 residents of which 10 resided in the Special Care Unit. The sample included 3 of the 10 resident who resided in the special care unit. Based on observation, record review and interview, the facility failed to provide an environment free from abuse for 1 of 3 sampled residents. (#2) This failure placed Resident #2 in immediate jeopardy Findings included: - Resident #2's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 6 which indicated severely impaired cognition. The assessment revealed the resident independent with ambulation, had steady balance, no behaviors, and did not wander. The 2/18/16 care plan stated the resident had impaired cognitive function, sometimes associated with agitation. The care plan further stated the resident needs supervision with all decision making and directed staff to cue, reorient and supervise as needed. The 3/29/16 at 6:37 PM, nurse's note stated staff notified the nurse to come to the (SCU) special care unit as soon as possible. The note stated an incident had occurred between Resident #2 and another resident. The note further stated the resident did recall being hit and pushed down and asked the nurse if he/she was bleeding. The resident had a small abrasion (scrape) to his/her left chin area with slight bleeding. The note stated the resident had been wandering in and out of other residents' rooms prior to the incident and wandered in to Resident #1's room when the physical fight started. On 3/31/16 at 2:00 PM, observation of the facility video, of the incident, revealed Resident #2 wandering down the hall in the SCU and into Resident #1's room and no staff visible. Further observation revealed Resident #1 pushed Resident #2 out of his/her room which caused Resident #2 to stumble and fall against the wall across the hallway. Resident #1 kicked Resident #2 while he/she was on the ground. As Resident #2 stood up, Resident #1 hit Resident #2 repeatedly with his/her open hand. Resident #1 continued to hit Resident #2 repeatedly and Resident #2 was unable to protect him/herself. Continued observation of the video revealed an unsampled resident, in the SCU slowly ambulating towards the two residents fighting in the hallway. The unsampled resident stopped, then walked around the two residents without incident. Observation revealed Resident #1 and Resident #2 talking to one another, then Resident #1 hit Resident #2 in the head again. Resident #2 turned around and walked down the SCU hall and stands by the nurse's station. Continued observation of the video revealed the residents unsupervised and no staff in the area. Resident #1 walked toward the couch in the commons area of the SCU and starts to sit down but notices Resident, #3, sitting in his/her favorite recliner. Resident #1 walks towards Resident #3 and at that time Nurse Aide C enters the area, and stands between Resident #1 and Resident #3. Continued observation revealed, Nurse Aide C walked over to Resident #2 and calls to Nurse Aide D who ran down the hall and out of the SCU doors. The POS, dated 2/16/16, indicated Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5 day MDS, dated [DATE], indicated the resident had long and short term memory problems with modified independence in decision making skills. The assessment revealed the resident independent with ambulation, had disorganized thinking, inattention, delusions, verbal behaviors towards others, rejection of care and wandered. The assessment further revealed the resident received daily antipsychotic and antidepressant medication and antianxiety medication, 1 day during the 7 day look back period. The 1/21/16 care plan stated Resident #1 had impaired cognitive functions and poor decision making skills. The care plan further stated the resident had behavior symptoms due to dementia, a previous altercation with another resident and directed the staff to intervene as necessary to protect the rights and safety of others. (although the facility video revealed no staff supervision at the beginning or during the physical fight between Resident #1 and Resident #2 on 3/29/16) The 2/16/16 physician's orders [REDACTED]. Review of the medical record revealed the facility had administered the [MEDICATION NAME] twice in the month of March, once on the 15th and, once on the 16th. The 3/29/16 at 7:00 PM, nurse's note stated there had been an physical altercation between Resident #1 and Resident #2 after Resident #2 went into Resident #1's room. The note stated Resident #1 pushed Resident #2 out of his/her room and Resident #2 fell to his/her knees. Resident #1 began slapping Resident #2 in the face several times with an open hand. The note further stated Resident #1 kicked at Resident #2 and proceeded to hit Resident #2 more. The note stated Resident #1 went over to Resident #3 who was sitting in a recliner and Resident #1 pulled Resident #3 out of the recliner. The note further stated the 6:00 PM shift arrived and the (DNS) director of nursing services informed them of the altercation between the two residents and directed the nurse coming on duty to administer, [MEDICATION NAME] (an antipsychotic medication) intramuscularly, as ordered by the physician to Resident #1. The note stated the DNS contacted the resident's physician who directed him/her to send the resident to a neighboring hospital for evaluation. The note stated the facility called the hospital and informed the (ER) emergency room staff of Resident #1's current and past resident to resident altercations and requested ER to evaluate Resident #1. The physician at the hospital stated the resident would be sent back to the facility if he/she did not display any behaviors. The note stated the resident started swinging at the nurse and refused the [MEDICATION NAME] injection so staff did not administer it. The DNS then directed a staff member to drive the resident to the hospital for evaluation but the resident refused numerous times. Multiple staff attempted to persuade the resident to go but he/she refused. The note stated the resident, while seated at the dining room table, took a metal butter knife and started to cut at the chair and then rubbed it on his/her sweats. The note stated the DNS called the local law enforcement for assistance in encouraging the resident to go for a ride in the van. Review of the medical record revealed the facility sent the resident to the hospital on [DATE] and he/she had not returned as of 3/31/2016. On 3/31/16 at 2:45 PM, observation revealed Resident #2 independently ambulating in the commons area. Further observation reveled a small scabbed area on the left side of his/her chin. On 3/31/16 at 10:35 AM, Nurse Aide D stated he/she had been in the whirlpool room with the door closed and did not see or hear the incident between the Resident #1 and Resident #2. Nurse Aide D stated when he/she left the whirlpool room, he/she observed a coworker talking to Resident #2 and noted the scrapes on Resident #2's face. Nurse Aide D stated he/she was not aware of the physical altercation until viewing it on the facility video. On 3/31/16 at 11:53 AM, Nurse Aide C stated he/she was assisting a resident in his/her room with the door closed, when he/she heard Resident #2 yelling but did not go out to check on him/her because the resident had been yelling off and on during the day. Nurse Aide C stated he/she did not see the incident between the two residents and did not know what had happened until viewing the incident on the facility video. On 3/31/16 at 1:00 PM, Administrative Nurse A stated there are two staff members that work the SCU and stated there should always be one staff member on the floor at all times. Administrative Nurse A stated the two staff members that were working in the unit were unaware of the incident until he/she showed them the incident on the facility's video. The 9/13 facility Abuse and Neglect Policy stated the resident has a right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, or volunteers. The facility failed to adequately supervise and prevent a physical altercation between Resident #1 and Resident #2, who sustained facial abrasions. The facility abated the immediate jeopardy on 4/7/16 after completion of training of all staff regarding utilizing the stop and watch program to send alerts to nurses regarding resident behaviors. The staff also received training regarding the facility's abuse and neglect policy, and reviewed behavioral causes and intervention training. The facility appointed a Special Care Unit Coordinator, and will round with the geri-psych physician to discuss behaviors occurring on the unit. The Social Service designee will monitor behaviors daily documented by the nurse aide, and the Director of Nursing will monitor behaviors documented by nurses. The deficient practice was abated to a scope and severity of a G.

The facility had a census of 63 residents. The sampled included 3 residents, who were all reviewed for therapeutic diets. Based on observation, record review, and interview the facility failed to assure 1 of the 6 sampled residents received and consumed foods in the appropriate form, as prescribed by the physician.(#1) Staff served Resident #1 a regular cinnamon roll, when his/her ordered diet was puree (blended to a consistency like mashed potatoes). The resident choked, became unresponsive, and required suctioning to remove the cinnamon roll. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 11/20/15, indicated the resident had unclear speech, rarely/never understood, sometimes understands others, had short and long term memory problems and severe impaired cognitive skills for daily decision making. The MDS indicated the resident required extensive staff assistance with eating, received a mechanically altered diet, and had no dental problems. The 11/20/15 care plan indicated the resident required swallowing techniques like alternate liquids and solids, double swallow, tongue sweep (brush across the tongue to remove food) to clear his/her mouth and the resident received a pureed diet. The 1/4/16 Speech Therapist evaluation recommend pureed food consistency for safety, after the resident's severe choking episode this morning, on a piece of a waffle. The 1/5/16 physician order [REDACTED]. The 1/5/16 at 8:15 AM nurse's note indicated the resident had a choking episode while eating breakfast, and recovered with assist of one staff. The 1/5/16 at 8:15 AM facility report stated the resident was reported as having an episode of choking while eating breakfast. The report stated the resident was eating a waffle soaked in syrup, began coughing with food in his/her mouth, and staff assisted the resident by providing back pats and the resident was able to remove the food. The report indicated the resident had a history of [REDACTED]. The report indicated the physician was notified and he/she ordered a pureed diet for the resident. The 1/6/16 Speech Therapist note indicated staff referred the resident to the Speech Therapist regarding the resident's choking episode. The Speech Therapist completed the assessment, and recommended puree foods and thin liquids. The note indicated the Speech Therapist recommended to allow soft and moistened deserts or snacks only if requested but must be cut up in tiny bites and the resident must be supervised while eating. The 2/3/16 at 4:20 PM nurse's note indicted staff observed the resident walking southward in the cove hall, he/she became weak and appeared to lose his/her balance. The note indicated a nurse was able to catch the resident and gently lower him/her. The resident became unresponsive and his/her facial color turned grayish. The note indicated a bolus of food was found in the resident's mouth that appeared to be occluding the airway, the staff rolled the resident onto his/her left side, then on his/her stomach in attempts to dislodge the material per back blows ( hard back slaps with the flat of the hand). The note indicated once staff rolled the resident onto his/her back with his/her head slightly elevated, staff applied suction to the resident's oral cavity. Staff obtained a moderate amount of soft food matter with a small amount of red drainage from the oral cavity. The note indicated the resident's color changed from gray to pale white to pink and he/she became verbally responsive. The 2/3/16 at 4:20 PM, the facility report indicated this was a repeat episode. The report indicated the resident was walking and eating a cinnamon roll, he/she choked on the cinnamon roll, passed out, and was lowered to the floor by staff. The report revealed staff suctioned a bolus (a small rounded mass of a substance, especially of chewed food at the moment of swallowing) of the cinnamon roll from his/her mouth. The report indicated a latch would be put on the refrigerator due to the resident's choking episode. Review of the Kardex ( a form with the resident's plan of care) revealed no documentation regarding types of food the resident was allowed to eat according to his/her pureed diet and Nurse Aide E verified the finding. On 2/10/16 at 10:24 AM, observation revealed an unlocked refrigerator on the cove unit that contained milk, pie of regular consistency, and pudding. Nurse Aide H stated the refrigerator in the cove should be locked. On 2/10/16 at 12:30 PM, observation revealed staff cued the resident to sit at the dining room table. Continued observation revealed the resident was served pureed sweet potato fries, mashed potatoes with gravy, pureed apple pork chops and regular consistency juice. On 2/11/16 at 2:20 PM, observation revealed the resident seated on a couch, in the cove commons area, with a box of Brach's sweetheart candy (small heart shaped hard sugar candy) in her hand. The resident had his/her eyes closed. Nurse C stated the resident probably picked them up somewhere in the unit. On 2/10/16 at 10:45 AM, Nurse Aide E stated if a resident was on a pureed diet, staff check in the kardex on the computer or ask the kitchen staff what type of food the resident could have. On 2/10/16 at 4:18 PM, Nurse Aide D stated, on 2/3/16 at about 4:00 or 4:30 PM, Nurse Aide D gave the resident one of the cinnamon rolls. A little while later Nurse B was leaving the cove unit and noticed the resident walking funny, called for help, and staff came to assist. Nurse Aide D stated the resident was getting short of air and slumped over, Nurse C lowered the resident to the floor, while Nurse B went to retrieve the vitals cart and suction cart. Nurse Aide D stated staff pulled the resident away from the wall and placed the resident on his/her stomach on the floor. Nurse Aide D stated the nurses were suctioning the resident's mouth, a chunk of the cinnamon roll came out, and the resident started breathing and crying. On 2/10/16 at 4:55 PM, Nurse Aide A stated on 2/3/16 at approximately 4:00 PM he/she saw Nurse Aide D give a cinnamon roll to Resident #1. Nurse Aide A stated the resident went down the hall eating the cinnamon roll. Nurse Aide A stated Nurse B was leaving the unit and noticed the resident was walking funny, the resident collapsed into his/her arms, Nurse B called for help, and staff came to assist. Nurse Aide A stated staff placed the resident on his/her side and Nurse C suctioned out a chunk of the cinnamon roll. Nurse Aide A stated he/she was aware the resident was on a pureed diet and never thought about it when Nurse Aide D gave the resident the cinnamon roll. On 2/10/16 at 10:28 AM, Nurse C stated on 2/3/16 at approximately 4:00 PM, staff prepared a tray of cinnamon rolls for the residents' snack. One of the nurse aides gave the resident one of the cinnamon rolls, and the resident choked on it. The resident lost consciousness, staff lowered him/her to the floor, and suctioned a bolus of the cinnamon roll out of the resident's mouth. Nurse C stated the resident received a pureed diet and he/she did not get to Nurse Aide D in time to retrieve the cinnamon roll from the resident. On 2/11/16 at 9:50 AM, Speech Therapy Staff F stated the resident could have bread products, as long as he/she was sitting down and they were really moistened with either syrup or butter, and they must be cut into small bites that are easy to chew. Speech Therapy Staff F stated he/she had several mini in-services with staff about what kind of foods the resident should have. On 2/10/16 at 11:38 AM, Administrative Nurse G stated the resident had a prior episode on 1/4/16, while he/she was eating a waffle, soaked in syrup, the resident began coughing, and the Speech Therapist was notified. On 2/10/16 at 3:28 PM, Administrative Nurse G stated he/she talked about what types of food a resident can have when receiving a pureed diet at staff meetings and when sitting around the residents assistive tables at meals. Administrative Nurse G stated nursing staff is responsible for making sure the refrigerator, in the cove unit, is locked. On 2/11/16 at 1:21 PM, Nurse C stated staff gave the resident a whole cinnamon roll on 2/3/16. On 2/16/16 at 1:30 PM, Nurse Aide D stated the nurse asked the resident to pass out the cinnamon rolls to the residents so he/she did. Nurse Aide D stated he/she knew the resident had a pureed diet but was not sure what dietary restrictions the resident had regarding a pureed diet. Nurse Aide D stated he/she had seen the resident eat many different foods in the past and was not told what he/she could or couldn't eat. The facility failed to ensure staff provided the physician ordered pureed diet to Resident #1, who had a history of [REDACTED]. When staff provided the resident a whole cinnamon roll, he/she lost consciousness and required suctioning. This deficiency practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 2/12/16, after completion of training of all facility staff regarding location of diet in the point click care, staff being served different diets to understand consistency differences, and understand the reason for residents needing different diets. The training will also include importance of following physician's orders [REDACTED]. The deficient practice was abated to a scope and severity of an D.

The facility had a census of 55 residents. The sample included 8 residents that were sampled for accidents of which 4 resided on the special care unit. Based on observation, record review and interview, the facility failed to provide adequate supervision and to adequately supervise and prevent an altercation for 1 of 8 residents reviewed for accidents who resided on the special care unit. (#2) This failure placed Resident #2 in immediate jeopardy. The facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 8 residents reviewed for accidents. Resident #4 fell out of a recliner and sustained a hematoma. Findings included: Resident #2's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 6 which indicated severely impaired cognition. The assessment revealed the resident independent with ambulation, had steady balance, no behaviors, and did not wander. The 2/18/16 care plan stated the resident had impaired cognitive function, sometimes associated with agitation. The care plan further stated the resident needs supervision with all decision making and directed staff to cue, reorient and supervise as needed. The 3/29/16 at 6:37 PM, nurse's note stated staff notified the nurse to come to the (SCU) special care unit as soon as possible. The note stated an incident had occurred between Resident #2 and another resident. The note further stated the resident did recall being hit and pushed down and asked the nurse if he/she was bleeding. The resident had a small abrasion (scrape) to his/her left chin area with slight bleeding. The note stated the resident had been wandering in and out of other residents' rooms prior to the incident and wandered in to Resident #1's room when the physical fight started. On 3/31/16 at 2:00 PM, observation of the facility video, of the incident, revealed Resident #2 wandering down the hall in the SCU and into Resident #1's room and no staff visible. Further observation revealed Resident #1 pushed Resident #2 out of his/her room which caused Resident #2 to stumble and fall against the wall across the hallway. Resident #1 kicked Resident #2 while he/she was on the ground. As Resident #2 stood up, Resident #1 hit Resident #2 repeatedly with his/her open hand. Resident #1 continued to hit Resident #2 repeatedly and Resident #2 was unable to protect him/herself. Continued observation of the video revealed an unsampled resident, in the SCU slowly ambulating towards the two residents fighting in the hallway. The unsampled resident stopped, then walked around the two residents without incident. Observation revealed Resident #1 and Resident #2 talking to one another, then Resident #1 hit Resident #2 in the head again. Resident #2 turned around and walked down the SCU hall and stands by the nurse's station. Continued observation of the video revealed the residents unsupervised and no staff in the area. Resident #1 walked toward the couch in the commons area of the SCU and starts to sit down but notices Resident, #3, sitting in his/her favorite recliner. Resident #1 walks towards Resident #3 and at that time Nurse Aide C enters the area, and stands between Resident #1 and Resident #3. Continued observation revealed, Nurse Aide C walked over to Resident #2 and calls to Nurse Aide D who ran down the hall and out of the SCU doors. The POS, dated 2/16/16, indicated Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5 day MDS, dated [DATE], indicated the resident had long and short term memory problems with modified independence in decision making skills. The assessment revealed the resident independent with ambulation, had disorganized thinking, inattention, delusions, verbal behaviors towards others, rejection of care and wandered. The assessment further revealed the resident received daily antipsychotic and antidepressant medication and antianxiety medication, 1 day during the 7 day look back period. The 1/21/16 care plan stated Resident #1 had impaired cognitive functions and poor decision making skills. The care plan further stated the resident had behavior symptoms due to dementia, a previous altercation with another resident and directed the staff to intervene as necessary to protect the rights and safety of others. (although the facility video revealed no staff supervision at the beginning or during the physical fight between Resident #1 and Resident #2 on 3/29/16) The 2/16/16 physician order's directed the staff to administer Haldol, 1(mg) milligram, (IM) intramuscularly, every 6 hours, as need for aggressive behavior. Review of the medical record revealed the facility had administered the Haldol twice in the month of March, once on the 15th and once on the16th. The 3/29/16 at 7:00 PM, nurse's note stated there had been a physical altercation between Resident #1 and Resident #2 after Resident #2 went into Resident #1's room. The note stated Resident #1 pushed Resident #2 out of his/her room and Resident #2 fell to his/her knees. Resident #1 began slapping Resident #2 in the face several times with an open hand. The note further stated Resident #1 kicked at Resident #2 and proceeded to hit Resident #2 more. The note stated Resident #1 went over to Resident #3 who was sitting in a recliner and Resident #1 pulled Resident #3 out of the recliner. The note further stated the 6:00 PM shift arrived and the (DNS) director of nursing services informed them of the altercation between the two residents and directed the nurse coming on duty to administer, Haldol (an antipsychotic medication) intramuscularly, as ordered by the physician to Resident #1. The note stated the DNS contacted the resident's physician who directed him/her to send the resident to a neighboring hospital for evaluation. The note stated the facility called the hospital and informed the (ER) emergency room staff of Resident #1's current and past resident to resident altercations and requested ER to evaluate Resident #1. The physician at the hospital stated the resident would be sent back to the facility if he/she did not display any behaviors. The note stated the resident started swinging at the nurse and refused the Haldol injection so staff did not administer it. The DNS then directed a staff member to drive the resident to the hospital for evaluation but the resident refused numerous times. Multiple staff attempted to persuade the resident to go but he/she refused. The note stated the resident, while seated at the dining room table, took a metal butter knife and started to cut at the chair and then rubbed it on his/her sweats. The note stated the DNS called the local law enforcement for assistance in encouraging the resident to go for a ride in the van. Review of the medical record revealed the facility sent the resident to the hospital on [DATE] and he/she had not returned as of 3/31/2016. On 3/31/16 at 2:45 PM, observation revealed Resident #2 independently ambulating in the commons area. Further observation revealed a small scabbed area on the left side of his/her chin. On 3/31/16 at 10:35 AM, Nurse Aide D stated he/she had been in the whirlpool room with the door closed and did not see or hear the incident between the Resident #1 and Resident #2. Nurse Aide D stated when he/she left the whirlpool room, he/she observed a coworker talking to Resident #2 and noted the scrapes on Resident #2's face. Nurse Aide D stated he/she was not aware of the physical altercation until viewing it on the facility video. On 3/31/16 at 11:53 AM, Nurse Aide C stated he/she was assisting a resident in his/her room with the door closed, when he/she heard Resident #2 yelling but did not go out to check on him/her because the resident had been yelling off and on during the day. Nurse Aide C stated he/she did not see the incident between the two residents and did not know what had happened until viewing the incident on the facility video. On 3/31/16 at 1:00 PM, Administrative Nurse A stated there are two staff members that work the SCU and stated there should always be one staff member on the floor at all times. Administrative Nurse A stated the two staff members that were working in the unit were unaware of the incident until he/she showed them the incident on the facility's video. The facility failed to provide adequate supervision to prevent a resident to resident altercation in which Resident #2 sustained an injury. The facility abated the immediate jeopardy on 4/7/16 after completion of training of all staff regarding utilizing the stop and watch program to send alerts to nurses regarding resident behaviors. The staff also received training regarding the facility's abuse and neglect policy, which will contain the 7 elements of abuse, and reviewed behavioral causes and intervention training. The facility appointed a Special Care Unit Coordinator, and will round with the geri-psych physician to discuss behaviors occurring on the unit. The Social Service designee will monitor behaviors daily documented by the nurse aide, and the Director of Nursing will monitor behaviors documented by nurses. The deficient practice was abated to a scope and severity of a G. - Resident #4's quarterly (MDS) Minimum Data Set assessment, dated 3/11/16, indicated the resident had long and short term memory problems with moderately impaired decision making skills, inattention and disorganized thinking. The assessment revealed the resident required extensive assistance of 2 staff members for transfers, bed mobility, and toileting, and had a previous fall with injury. The 3/24/16 care plan stated the resident cognitively impaired, had episodes of confusion, and poor judgement, was extremely hard of hearing, and a risk for falls. The care plan directed the staff to use a mechanical lift and 2 staff members for transfers and to provide a personal alarm at the head of the resident's bed to alert staff of his/her movements. The 3/24/16 at 8:15 PM, facility fall investigation indicated while the resident was seated in a rocker recliner, he/she put the foot rest down, scooted to the edge of the chair, causing the chair to tip, and he/she fell out. The investigation stated the staff changed the rocker recliner out for a recliner that does not rock forward. The 3/24/16 at 10:24 PM, nurse's note stated the resident was taking a nap in a recliner in the dining room area. The resident woke up and he/she put the footrest down on the recliner, the nurse on duty, put the footrest back up, and told the resident he/she would be back to assist him/her after he/she administered medication to another resident. The note further stated when the nurse returned, the resident was lying on the floor, on his/her right side and trying to get up. The note stated the resident had a hematoma (collection of blood under the skin) on the right side of his/her head. The staff notified the physician who directed the staff to perform neurological checks every 15 minutes for 1 hour, at 2:00 AM, and again at 6:00 AM. On 3/30/16 at 9:13 AM, observation revealed Licensed Nurse D and Licensed Nurse C were assisting the resident to transfer to his/her bed. The resident repeatedy asked the nurses for help and Nurse C tried to explain to the resident they were going to assist him/her to bed. The resident kept hollering, can somebody help me? Further observation revealed Nurse C bending down to the resident and talking in his/her right ear but the resident did not understand or would voice something different than what the nurse had said. On 3/29/16 at 5:45 PM, Licensed Nurse D stated the resident had been asleep in a recliner, woke up and put the footrest down. Licensed Nurse D stated the resident asked for assistance but he/she was getting another resident's medication ready so he/she told the resident he/she would help him/her in a minute. Licensed Nurse D stated, he/she went over to the resident, put the footrest back up and told him/her that he/she would be right back. Licensed Nurse D stated he/she was only gone for a couple minutes and the nurse aides on the floor were assisting other residents when the resident had fallen out of the recliner. Licensed Nurse D stated the rocker recliner has been exchanged for a stationary recliner. On 3/30/16 at 11:00 AM, Administrative Nurse A stated the nurse should have assisted the resident before he/she administered medications to another resident. The July 2015 facility's Fall Prevention and Management Policy stated the purpose is to identify risk factors and implement interventions before a fall occurs. An avoidable accident means that an accident occurred because the staff failed to identify environmental hazards and individual resident risk of an accident, including the need for supervision and/or evaluate and analyze the hazards and risks. The facility failed to provide adequate supervision and assistance to prevent Resident #4 from falling out of a recliner and sustaining a hematoma.

The facility had a census of 64 residents. The sample included 6 residents, of which 3 were reviewed for accidents. Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards, and adequate supervision, for 1 of 3 residents who fell in the special care unit dining room and sustained a fractured arm (#3). The facility failed to provide adequate supervision to prevent resident to resident altercations between 2 of 3 residents reviewed, which could result in potential for harm, who resided in the special care unit. (#2, #5) Findings included: - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 3/20/15, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 8, exhibited delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), physical behaviors directed toward others, rejection of care, and wandering behaviors. The MDS further indicated the resident required limited assistance from 1 staff for bed mobility, and transfers, and required extensive assistance from 1 staff for toilet use, personal hygiene, and dressing. The MDS further indicated the resident had unsteady balance, only able to stabilize with staff assistance when moving from seated to standing, and a walker. The MDS indicated the resident was frequently incontinent of bowel and bladder, had a non-injury fall, and received antipsychotic and antidepressant medications. The 1/26/15 fall (CAA) Care Area Assessment informed staff the resident required counterbalance with his/her walker with transfers and ambulation, incontinent, and unaware of his/her need to void. The 3/23/15 care plan informed staff the resident had an unsteady gait, a fall with minor injury related to getting up without assistance, and instructed staff to educate the resident to ask staff for his/her walker when getting up from the dining room table. The care plan further instructed staff to ensure the resident wore appropriate footwear when walking and transferring. The 6/12/15 care plan update instructed staff to provide assistance of 1 staff with use of a gait belt, with transfers and ambulation. The 1/19/15 fall risk assessment indicated the resident was a medium risk for falls. The 6/12/15 at 4:02 PM, nurse's note revealed staff found the resident lying on the floor in the dining room, on his/her back, in-between the nurse's desk and the medication cart, holding his/her right shoulder. The note further indicated staff observed an abrasion to the resident's right elbow which measured 2.0 (cm) centimeters x 0.5 cm, with no drainage. The note indicated staff reviewed the facility's camera monitoring system, and witnessed the resident lose his/her balance when attempting to stand up, and he/she reached back with the right arm to brace the fall. The 6/12/15 physician's orders [REDACTED]. The 6/12/15 at 10:50 PM, nurse's note indicated the resident held his/her right arm with the left hand, and stated his/her shoulder hurt. The note indicated staff administered scheduled Norco (a narcotic pain medication). The 6/12/15 facility investigation indicated the resident's fall was unwitnessed by staff, and had to be viewed on the surveillance camera to know what happed. the investigation further stated the resident was observed on the camera trying to maneuver around items located in the dining room, lost his/her balance, and was without his/her walker. The 6/13/15 at 10:30 AM, nurse's note indicated the resident returned from the physician's office with a sling in place due to a right proximal impacted humerus fracture. The 6/13/15 physician progress notes [REDACTED]. The physician further documented the resident was unable to provide a history due to severe dementia, and was holding his/her arm in a splinted position. The progress note indicated the resident had moderate to severe swelling on the proximal humeral region (arm), tender throughout the region, and painful range of motion. The progress note further indicated the resident's x-ray revealed an impacted humeral neck (arm) fracture, and the physician placed the resident's right arm in a sling. On 8/17/15 at 12:45 PM, observation of the dining room of the special care unit, revealed several residents seated around 2 tables eating their noon meals. Continued observation revealed a large desk in the corner of the room and a medication cart beside the desk, next to the dining room table, leaving no room to walk through. Further observation revealed staff asked residents to get up and move during their meal, so staff could move the medication cart, due to the crowded room. On 8/18/15 at 8:30 AM, observation revealed the resident seated in a chair in the dining room, with his/her walker, eating his/her morning meal, with staff supervision. On 8/18/15 at 9:30 AM, Nurse B verified staff found the resident on the floor in-between the medication cart and the desk, and the resident was mad because there was not enough room for him/her to move. Nurse B further verified the staff did not witness the resident's fall, due to providing care to other residents, and there are several times the residents are left unattended in the commons area of the facility. On 8/18/15 at 10:24 AM, Administrative Nurse A verified the dining room is cluttered, and this contributed to the resident's unwitnessed fall, which resulted in a fracture. Administrative Nurse A further verified staff had not provided the resident with a sling as ordered by the physician. Administrative Nurse A further verified he/she expected 1 staff to be on the floor at all times to monitor the residents. The facility failed to provide an environment free of accident hazards by the dining room being overcrowded, and provide adequate supervision for Resident #3, who fell and sustained a fracture. - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 7/10/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, no behaviors, and required limited assistance of 1 staff for bed mobility and transfers, and extensive assistance of 1 staff for dressing, toilet use, and personal hygiene. The MDS indicated the resident had steady balance, 1 non injury fall, and received antipsychotic, antianxiety, antidepressant, and anticoagulant medications. The 7/23/15 care plan indicated the resident had a behavior symptom related to dementia (progressive mental disorder characterized by failing memory, confusion) evidenced by aggression toward other residents. The care plan instructed staff to intervene as necessary to protect the rights and safety of other residents, approach the resident in a calm manner, divert his/her attention, remove the resident from the situation, and take to an alternative location as needed. The care plan further instructed staff to provide distance between residents, to observe for heightened tensions between residents, and to separate prior to any altercation. The care plan informed staff the resident had behaviors of moving furniture, and instructed staff to allow the behavior as long as he/she was not harming his/herself or other residents. The care plan further informed staff the resident had a behavior of becoming agitated at other residents and may feel staff or other residents are at risk for harm, instructed staff to get in front of the resident, and inform him/her everyone is okay, and no one will be harmed. The 6/6/15 at 11:20 AM, nurse's note indicated the resident often would become aggressive with other residents, and was easily redirected at times. The 6/30/15 at 11:12 AM, nurse's note indicated the resident had an unwitnessed interaction with another resident, had pushed another resident to the floor, and nursing eventually arrived to separate the residents. The 7/19/15 at 10:09 AM, nurse's note indicated the resident and his/her roommate were holding hands tightly, shoving each other back and forth. The note further indicated the resident was shoved out of his/her room, by his/her roommate and they had began to fight. The nurse's note indicated the resident received no injuries and staff would keep the resident's separated. (The residents remained roommates during the onsite visit.) The 8/1/15 at 3:23 PM, nurse's note indicated the resident was grabbed by another resident while ambulating in the dining room. The nurse's note further indicated the other resident would not release him/her until staff came and intervened to separate the residents. The nurse's note stated the resident received a skin tear which measured 2.5 (cm) centimeters by 1.25 cm to his/her left elbow. On 8/18/15 at 8:33 AM, observation revealed the resident in the commons area of the special care unit, pushing a dining room chair around the area. Further observation revealed the resident attempted to move a recliner in the commons area, and staff redirected the resident to eat his/her morning meal. On 8/17/15 at 3:01 PM, Nurse D verified the resident had an unwitnessed altercation with his/her roommate, which was viewed on the surveillance video. Nurse D stated staff were in with another resident and had left the other resident on the unit unattended. On 8/17/15 at 10:16 PM, Medication Aide C verified during the night shift, if there is a resident up, he/she would have to leave them unattended to do cares with other residents. Medication Aide C stated he/she will sometimes give the resident a snack to keep him/her occupied while he/she is providing cares to other residents. On 8/17/15 at 10:48 PM, Nurse E verified the resident still resides with his/her roommate due to there being no other rooms available in the special care unit. Nurse E stated the resident has had past altercations with the other residents in the unit, of the same gender. Nurse E stated that during the night shift there is only 1 staff in the special care unit, and residents will be left unattended if they are up, while the staff are providing cares to other residents. On 8/18/15 at 10:24 AM, Administrative Nurse A verified he/she expected 1 staff to be on the floor at all times to monitor the residents and intervene if necessary with resident behaviors, and verified staff failed to provide appropriate supervision. The facility failed to adequately supervise residents and redirect behaviors for Resident #2, which resulted in multiple unwitnessed resident to resident incidents. - Resident #5's quarterly (MDS) Minimum Data Set assessment, dated 7/3/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 2, exhibited delusional behaviors, and was independent with (ADLs) Activities of Daily Living. The 7/16/15 care plan informed staff the resident had behavior symptoms related to dementia evidenced by agitation and physical aggressiontoward others. The care plan instructed staff to intervene as necessary and protect the rights and safety of others, approach and speak in a calm manner, divert attention, and remove from the situation and take to an alternate location. The care plan informed staff the resident displayed delusional behaviors and to allow him/her to think he/she owned the building, and it was harmless behavior. The care plan further instructed staff if the resident became aggressive, remove him/her from the area, take him/her for a walk, and to provide a snack or other distraction. The 7/19/15 at 9:30 AM, nurse's note indicated the resident walked out of his/her room quickly and pulled another resident down to the ground. The 7/19/15 at 10:00 AM, nurse's note indicated the resident had an altercation with his/her roommate, in which they were holding hands tightly and and shoving each other back and forth. The note further indicated the resident pushed his/her roommate out of the room, and they had began to fight. (During the onsite visit, the residents remained roommates.) The 7/19/15 12:52 PM, nurse's note indicated after reviewing the surveillance camera, the resident was viewed coming down the hall and had pulled another resident to the floor, stating he/she had been in his/her room. The 7/26/15 at 7:45 AM, nurse's note indicated the resident tearfully complained of being fearful of his/her roommate, and refused to go into his/her room. (During the onsite visit, the residents remained roommates.) The 8/1/15 at 3:23 PM, nurse's note indicated the resident had aggressive behavior which resulted in personal contact with another resident, and the resident held another resident on the floor with a wrestling hold, until staff arrived and separated the residents. The 8/2/15 at 2:27 AM, nurse's note indicated the resident was restless and did not appear to be in good spirits, and stated he/she could not sleep with his/her roommate in the room. (During the onsite visit, the residents remained roommates.) On 8/17/15 at 1:58 PM, observation revealed the resident moving about the special care unit, going to his/her room, and to different chairs in the commons room. At 2:33 PM, observtion revealed the resident seated at the dining room table to play cards alone. On 8/17/15 at 3:01 PM, Nurse D verified the resident had an unwitnessed altercation with his/her roommate, that was viewed on the surveillance video. Nurse D stated staff were in with another resident and had left the resident on the unit unattended. On 8/17/15 at 10:16 PM, Medication Aide C verified during the night shift, if a resident's up, he/she would have to leave them unattended to do cares with other residents. Medication Aide C stated he/she would give the resident a snack to keep them occupied while he/she is provided cares to other residents. On 8/17/15 at 10:48 PM, Nurse E verified the resident still resides with his/her roommate due to there being no other rooms available in the special care unit. Nurse E stated the resident had past altercations with the other residents in the unit, of the same gender. Nurse E stated that during the night shift there is only 1 staff in the special care unit, and residents will be left unattended if they are up, while the staff are providing cares to other residents. On 8/18/15 at 10:24 AM, Administrative Nurse A verified he/she expected 1 staff to be on the floor at all times to monitor the residents and intervene if necessary with resident behaviors, and verified staff failed to provide appropriate supervision. The facility failed to adequately supervise residents and redirect behaviors for Resident #5, which resulted in multiple unwitnessed resident to resident incidents.

The facility had a census of 59 residents. The sample included 4 residents. Based on observation, interview and record review the facility failed to provide a safe environment and adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents. (# 4) Findings included: - Resident #4's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 12/6/13, indicated the resident had a severe cognitive impairment with a (BIMS) Brief Interview for Mental Status Score of 3. The MDS further indicated the resident required limited assistance from 1 staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated the resident had not experienced any falls since the prior assessment although his/her balance was not steady and he/she was only able to stabilize with staff assistance. The fall (CAAs) Care Area Assessment, dated 4/5/13, indicated the resident received Lasix (a diuretic medication) which causes increased urination and urgency. The CAA indicated he/she had dementia and decreased awareness of safety limitations, was legally blind and wanders. The 10/14/13 care plan directed the staff to remind the resident to use his/her walker and directed the staff to obtain orthostatic blood pressures and notify the physician with the results. On 12/13/13 the resident sustained [REDACTED]. The care plan was reviewed on 12/20/13 without any additional changes. On 12/23/13 the resident sustained [REDACTED]. On 12/24/13 the resident sustained [REDACTED]. Review of the care plan revealed the care plan lacked issues identified in CAAs. The 12/16/13 fall risk assessment indicated the resident was a high fall risk. Review of the December 2013 facility nursing schedule indicated the facility had 1 nurse aide and 1 nurse scheduled for the special care unit from 6 AM until 8AM on 12/23/13. Further review indicated the nurse scheduled for the special care unit is also responsible for another hall located across the main hallway approximately 30 feet from the entrance of the locked special care unit. The 12/23/13 at 7:48 AM, nurse's note indicated the resident fell in the dining room and on his/her right hand the 4th and 5th digit ends were actively bleeding with the skin and nails torn off. The 12/23/13 physician's progress note indicated the x ray revealed a comminuted fracture (the bone is in many pieces) of the 4th and 5th distal phalanx (finger) and a suture was placed on the 4th avulsion (an injury in which a body structure is forcibly detached from its normal point of insertion by either trauma or surgery), the rest of the tissue was denuded (the act or process of removing surface layers) enough and couldn't be approximated (to bring together, as cut edges of tissue). The physician applied tube gauze dressings to give pressure. The physician's assessment revealed a fracture of the 4th and 5th distal fingers of the right hand with an open wound. The 12/23/13 Radiology report indicated the resident has a comminuted fracture (the bone is in many pieces) at the distal (away from the center of the body) tip of the phalanx (finger bones) of the 4th and 5th fingers of the right. On 1/8/14 at 1:06 PM, observation revealed the resident seated in the dining room of the special care unit eating lunch. Further observation revealed the resident had a bandage on his/her right hand covering his/her 4th and 5th fingers. After the resident finished eating continued observation revealed the resident ambulating to his/her room using a walker with staff assistance. On 1/13/14 at 2:45 PM, observation of the facility's video of the special care unit, during the time and date of the fall, revealed the resident seated in a chair in the special care unit commons area at 7:45 AM on 12/23/13. Continued observation revealed no staff visible and the resident's walker not beside him/her. Further observation revealed the resident reached for something out of sight of the video and the resident fell and was assisted by other residents to stand up and be seated at the dining table. The resident stood independently from the dining table and walked away before the staff had assisted him/her. On 1/8/14 at 3:54 PM, Nurse Aide E verified the resident needed to be reminded to use his/her walker and if the resident did not use it the staff would have to get it for him/her to use. On 1/13/14 at 1:09 PM, Nurse D verified he/she was not scheduled to work on the special care unit the morning the resident fell until 8 AM. There was a nurse aide scheduled that morning to assist the residents with morning care and getting up for the day. Nurse D further verified the facility usually does have 2 staff members scheduled in the special care unit, but sometimes only 1 staff is scheduled. On 1/13/14 at 1:16 PM, Nurse B verified he/she was scheduled as the special care unit nurse on the morning of the resident's fall with injury on 12/23/13. Nurse B further verified the morning of the resident's fall he/she was passing medications to other residents in the main dining room outside of the locked special care unit. On 1/13/14 at 2:59 PM, Administrative Nurse A verified there was 1 nurse on duty for the special care unit at the time of Resident #4's fall. The nurse who was also responsible for another hall and a nurse aide was scheduled on the special care unit. Administrative Nurse A further stated the housekeeper scheduled in the special care unit is a nurse's aide and could help if needed. On 1/13/14 at 3:00 PM, Housekeeping Staff C verified he/she was working in the special care unit at the time of the resident's fall with injury and he/she had observed the resident on the floor. He/she had come from cleaning a resident room and he/she witnessed 2 other male residents assisting the resident to stand up. Housekeeping Staff C verified he/she notified the nurse aide, who was in another resident's room. Housekeeping Staff C further verified he/she helps the nursing staff when asked by the staff, but is scheduled as a housekeeper. On 1/15/14 at 1:20 PM, Physician Office Staff I verified the resident was seen on 12/23/13 by the physician for an injury to the fingers. The facility failed to provide a safe environment and adequate supervision to assist in the prevention of falls for Resident #4 who fell and sustained injuries including fractures of 2 fingers.

The facility had a census of 60 residents. The sample included 14 residents of which 3 were reviewed for nutrition and weight loss. Based on observation, record review and interview, the facility failed to ensure 1 of 3 residents maintained nutritional status. Resident #25 had an avoidable significant weight loss of 15 percent in 6 months. Findings included: - Resident #25's medical record revealed [DIAGNOSES REDACTED]. Review of the resident's weight record revealed the following weights: 1) 5/10/10-146# 2) 6/25/10-139.5# 3) 7/27/100-139# 4) 8/26/10-135# 5) 9/30/10-129#-a 11.6% weight loss (10% in 6 months or less is a significant weight loss) 6)10/15/10-128# On 11/8/10, the surveyor requested the facility staff weigh the resident and Nurse C reported the resident's current weight at 124 pounds, a significant weight loss of 15 percent in 6 months. On 11/3/10 at 3:00 PM, observation revealed a package of crackers in a basket on the floor in the resident's room. On 11/4/10 at 8:23 AM, observation revealed the resident received a room tray at their request. Observation revealed the breakfast tray included 2 pieces of french toast, 1 sausage patty, 240 (ml) milliliters of milk, 240 ml of water and 240 ml of coffee with cream. At 9:00 AM, observation revealed the resident had eaten 100 percent of their breakfast. The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 10/20/10, indicated the resident had no short or long term memory loss and modified independence with decision making skills. The MDS indicated the resident was independent with staff set up assistance with their activities of daily living, including eating. The MDS indicated the 5'6" resident weighed 128 pounds. The MDS indicated the resident received a therapeutic diet. The MDS had no indication the resident had a significant weight loss. The 10/28/10 care plan indicated the resident at nutritional risk and directed the staff to provide their diet as ordered which included fluids with their meals. The care plan indicated the resident preferred their meals in their room and the resident was able to obtain their own fluids in between meals. The care plan directed the staff to monitor the resident to meet their nutritional needs and to provide a snack basket in their room at all times. Review of the (RDLD) Registered Dietician notes, dated 3/10/10, revealed the resident's weight at 156.5 pounds and their daily estimated needs of 1600 calories, 71 grams of protein and 2,130 milliliters of fluid. The facility (CDM) Certified Dietary Manager notes, dated 5/13/10, indicated the resident weighed 146 pounds and received a diet of high protein and large portions. The CDM notes indicated the resident remained in their room for meals per their request. The CDM notes indicated the staff were to monitor the resident's needs, ensure their needs were met and offer the resident snacks as the resident desired. The 9/14/10 RDLD notes indicated staff discussed the resident at the nutritional risk meeting regarding the resident's weight, of 135 pounds, a weight decrease of 11 pounds in 4 months. The RDLD notes indicated the staff would review the resident's weight in 30 days. Review of the medical record revealed no new interventions although the staff had identified the resident had a 7.5% weight loss in approximately 4 months. The 10/15/10 RDLD notes indicated the staff discussed the "at nutritional risk" weight for the resident at 129 pounds and the resident's undesirable weight loss. The note further indicated the facility's dietary manager planned to visit with the resident to see what the resident would eat extra to increase his/her calorie intake. The 10/28/10 CDM notes, indicated on 10/15/10 the resident weighed 128 pounds, down from 135 pounds on 8/10/10 and 139.5 pounds in July 2010. The notes indicated the resident's diet remained the same and the staff offered snacks. The notes indicated the staff would check with the resident's physician in regards to a need for supplement and plan to continue to offer snacks between meals and at bedtime. The notes indicated a snack basket would be placed in the resident's room and the resident was interviewed in regards to their likes and dislikes. The notes indicated the resident refused meals at times. Review of physician progress notes [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 11/4/10 at 1:30 PM, Dietary Staff E verified no dietary supplement or fortified foods were provided to the resident. Dietary Staff E further verified the resident received high protein and large portions at meals. Dietary E confirmed the resident's breakfast tray the surveyor observed, on 11/4/10 at 8:23 AM, should have included 2 sausage patties to meet the high protein and large portions servings. On 11/4/10 at 2:30 PM, Nurse Q indicated the they were aware of the resident's weight loss. Nurse Q further indicated they were not aware of the significant loss of 15 percent in less than 6 months. On 11/4/10 at 3:20 PM, Nurse R verified they were aware of the resident's weight loss. Nurse R further verified no other interventions or supplements were offered to the resident to maintain the resident's weight. The facility failed to ensure Resident #25 maintained acceptable levels of nutritional status. The resident had a significant weight loss of 15 percent in less than 6 months.